Through its proper officer or agent, each licensee promptly shall notify the Commissioner of the name, title, and address of each individual the licensee desires to appoint as a representative in the State. The notice required by this section shall be: filed with the Commissioner on the form that the Commissioner provides; and accompanied by: an initial registration fee of $5; and a statement in writing, by the appointee, that gives: the appointee’s name, age, residence address, business address, present occupation, and occupation for the 5 years immediately preceding the date of the notice; the names of motor clubs represented during the 5 years immediately preceding the date of the notice and where represented; and any other information the Commissioner requires.