| Name:* |
|
| Address: |
|
| City: |
|
| State: |
|
| Zip Code: |
|
| Phone: |
|
| Fax: |
|
| E-mail:* |
|
| Type of Firm: |
|
| Current Commission Range: |
|
| Assets Under Management: |
|
| Product Focus: |
|
| What is your time frame? |
|
| Current Licenses: |
Series 4
Series 6
Series 7
Series 22
Series 8 or 24
Series 63
Series 65
Life and Annuity licensed
Other |
| Other Licenses: |
|
Approximate Product Mix Break Down: |
% Equities
% Fee-based Asset Mgmt
% Financial Planning Fees
% Fixed Annuities
% Life Insurance
% Mutual Funds
% Options
% Variable Annunities
% Variable Life |
| What are the most important factors in choosing a broker dealer? |
|
| How did you hear about us? |
|
| Comments: |
|
| |
|