INSTRUCTIONS (it’s easy as 1, 2, 3):    

1.      Fill out application, sign and date it

2.      Clip a wallet size or 4x6 photo (head-shot only) to form. Note: photos will not be returned.

3.      Send five dollars ($5) cash or money order only to: Auto Insurance Data, Attn: Louis Edwards, 3186 Franklin Avenue, San Diego, CA 92113. (To keep cost down send a self-addressed envelope.)

(Please print clearly.) 

NAME:                                                                                   

ADDRESS:                                                                              

CITY:                                      STATE:                ZIP:              

SEX:                HAIR COLOR:                       EYES:                   

HEIGHT:               WEIGHT:                BIRTH DATE:                 

TELEPHONE: (           )                           

 

CERTIFICATION

 I hereby certify that all information contained herein is true and accurate to the best of my knowledge. I agree to hold harmless and free of all liability (for whatsoever reason) Auto Insurance Data and all its personnel. NO WARRANTIES IMPLIED.

                                                                                         

Signature (parent or guardian)                     Date