inkWELL Authorized Agent Request

Authorized Agent Request

Step 1 of 2 – Please Declare Your Residency

Your client must be a California Resident to complete this form.
You must be an authorized agent with a license to practice in California in order to complete this form.
Is your client a California Resident?
- Yes
- No
Are you an Authorized Agent?
- Yes
- No
Authorized agents are someone that acts on a consumers behalf. Click this only if you are submitting this form on behalf of someone else.
What is Your Client's ZIP Code?*

Type of Request (On Behalf of Client)*
Client Information
Client's First Name*
Client's Last Name*
Client's Address*
Street Address Address Line 2 City State ZIP Code
Agent Information
Agent's First Name*
Agent's Last Name*
Agent's Address*
Street Address Address Line 2 City State ZIP Code
Agent's Phone*
Agent's Email*