DFS-H2-1544TERM 69B-221.155 F.A.C.
Revised 04/11
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services - Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
Name and Address of Appointing Entity
Company Code
Temporary Limited Surety Agent (T2-35), Limited Surety Agent (2-34),
Professional Bail Bond Agent (2-37) and Managing General Agents
For Bail Bond Business (0-60)
Appointment TERMINATION Form
Print or Type
Part I
Section Section Section Section Section
1 2 3 4 5
License Number
Last Name, First Name and Middle Initial
County
Type &
Class of
Effective Date of
/ /
PART II (to be completed by appointing company representative)
REASON: EXPLANATION:
LICENSEE REQUEST ___________________________________________________
DECEASED (ATTACH PROOF)
NO LONGER REPRESENTS COMPANY ___________________________________________________
ALLEGED VIOLATION OF THE FLORIDA STATUTES
___________________________________________________
___________________________________________________
Signature of Appointing Official, or Agent (self termination)
Print/Type Name of Appointing Official or Agent (self termination)
Title Date
Business Phone License # (if applicable)
This form must be signed by an official of the appointing entity. This signature verifies that appropriate notice of termination has been
given to the appointee pursuant to §648.39, Florida Statutes. Otherwise, this form must be signed by the appointee if he or she is
requesting termination of the appointment themselves.
Return to:
Department of Financial Services
Bureau of Licensing
200 E Gaines Street
Tallahassee FL 32399-0319
