PROFESSIONAL AFFILIATION APPLICATION

First Name

Last Name

Company

Email Address

Business Address:

Is This a Residential Address? Is This a Residential Address? Yes No

Shipping Address: (If different from your business address - Cannot be a P.O. Box)

Is this a Residential Address? Is this a Residential Address? Yes No

PROFESSIONAL Designations: PROFESSIONAL Designations: CPA CFP CLU ChFC CSA CEP RFP

PROFESSIONAL Licenses/Designations Cont'd: PROFESSIONAL Licenses/Designations Cont'd: Series 7 Series 6 Series 65 Real Estate Broker Real Estate Agent Other: Please List Below

Please List any other Professional Licenses or Designations

Broker Dealer:

Your Company Website:

The States I Practice In Are:

PRODUCTS & SERVICES I PROVIDE: PRODUCTS & SERVICES I PROVIDE: SECURITIES MUTUAL FUNDS ANNUITIES PENSION PLANS IRA'S LEGAL/PROBATE TRUSTS/WILLS

PRODUCTS & SERVICES I PROVIDE: PRODUCTS & SERVICES I PROVIDE: ESTATE PLANNING TAX SERVICES BANKING CD'S LEGAL/PROBATE TRUSTS/WILLS OTHER: Please list below

Other products & Services I provide are:

ATTORNEYS ONLY: State Bar# & Admission Date(s)

ATTORNEYS ONLY: States Admitted:

How did you hear about us?

Have you ever had any disciplinary or legal action, past, present, pending or current, by any State or Government agency taken against you or your firm? Have you ever had any disciplinary or legal action, past, present, pending or current, by any State or Government agency taken against you or your firm? Yes No

If yes, please explain:

Please provide 3 business references who have know you for more than three years, including contact information:

I am an.... I am an.... Advisor-Planning Professional Attorney Attorney & Provide Planning Services

By Signing and Submitting my application, I certify that all of the information contained in this application and any attachments submitted, are true and correct, and I agree to the applicable Advisor and/or Attorney Agreement(s) By Signing and Submitting my application, I certify that all of the information contained in this application and any attachments submitted, are true and correct, and I agree to the applicable Advisor and/or Attorney Agreement(s) I Agree

My SIGNATURE:

DATE: