Insurance License Application

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Please correct the fields below:

Please correct the field(s) marked in red below:

Applicant

*

Applicant

Company Name:

Address:

Name:

Title:

Phone Number:ext.

Email Address:

Application Year:

Payment Method:

Card

Check

By signing below, I understand that there is a $150.00 fee per office location and that the fee is due by January 31st annually.

*

Signature (Please type your full name in lieu of your signature):

Date:

The fee can be paid online by credit or debit card after processing is complete at www.roswellgov.com/GeneralBilling.

Alternatively, checks can be mailed to:

City of Roswell
38 Hill Street, Suite 120
Roswell, GA 30075

If you have any questions, please contact Financial Services Division at fsd@roswellgov.com or 770-641-3759.

To receive a copy of your submission, please fill out your email address below and submit.
Email Address