First Name:
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Last Name:
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Address:
City:
State:
Zip:
Country:
Office Phone:
Home Phone:
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Fax:
Email:
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Current Broker/Dealer/Firm:
Type of Firm:
Please Choose:
Wire House
Regional
Insurance Company
Accounting Firm
Other Independent Firm
Not Currently Licensed
Current Commission Range:
Please Choose:
Above $1,000,000
$500,000 - $1,000,000
$200,000 - $500,000
$125,000 - $200,000
$60,000 - $125,000
Under $60,000
Assets Under Management:
Please Choose:
0-$9 Million
$10-20 Million
$21-50 Million
$51-100 Million
$101 Million +
Years in retail security sales:
Please Choose:
Under 3
3 - 5
5 - 10
10 - 15
15+
Product Focus:
Please Choose:
Mutual Funds
Insurance
Fixed Income
Equities
RIA?
Please Choose:
Yes
No
I am a:
Please Choose:
Stockbroker
Insurance Agent
Financial Planner
Investment Advisor
Other
What is your time frame?
Please Choose:
Immediately
Next 2 months
Next 6 months
Within 1 year
More than 1 year
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 Income
% 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?
Please Choose:
Registered Rep
On Wall Street
Financial Planning
Ticker
Dow Jones Invest. Advisor
Other
If other, please specify:
Where and when would you like to be contacted?
Questions or comments:
Note: Any information submitted here will be kept confidential for your privacy .
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