Founders Financial, Inc. - Confidential Member Inquiry

If someone is seeking a relationship with the best producer group and wants to associate themselves with like-minded, high quality professional, Founders Financial is the place to be. D Bauernschub, CLU, ChFC

Thank you for your interest in Founders Financial. At Founders, what sets us apart from other producer groups is exactly what makes us so strong - it's our commitment to our Members, to their success, and to our shared values. If you are ready to experience the difference and would like to schedule a one-on-one consultation with Founders CEO, Michael Brooks or to learn more about or to be considered for membership, please complete the information request form below.

By completing and submitting this information request form, you are hereby granting Founders Financial and its entities authorization to conduct a background review that may include, but is not limited to, employment, insurance licensing, securities registration, job performance history, academic records, credit records, disciplinary, arrest and conviction records, personal history; including information as to character, general reputation and mode of living.

* Required fields

Contact Information

* Full Name:

* Business Name:

* Title:

* Business Address:

(* Street)


(* City)	(* State)	(* Zip)

* Business Phone:		* Business Fax:
* Email Address:		Web Address:
Tax ID or Social Security No.:

* Area(s) of Specialization:

* How many years have you been in business?

* Current B/D:

Current Insurance Resources:

* What licenses do you hold?

CLU	ChFC	CFP	CEP	CSA
Series 6	Series 7	Series 24/26	Series 63	Series 65/66
Other:

Production and Target Market Data

* What is your average annual production?

* Comprised of:

GDC: $		Insurance: $
Fee: $		Other: $

From where are your current revenues derived?

% of activity

	% Qualified Plans		% Financial Planning
	% Non-Qualified Plans		% Disability Income
	% Business Insurance		% Long Term Care
	% Estate Planning		% Employee Benefits
	% Charitable Planning		% Capital/Asset Management
			% Other:

What are your target markets?

	% Family Markets		% Executive Companies
	% Small Business		% High Net Worth
	% Senior Markets		% Professional Athletes
			% Other:

What is your approximate product mix break down?

	% Wrap Account Managment Fees		% Stocks
	% Separate Account Management Fees		% Municipal Bonds
	% Financial Planning		% Taxable Bonds
	% Mutual Funds		% UITs
	% Variable Annuities		% Options
	% Fixed Annuities		% Limited Partnerships
	% Variable Insurance		% Covered Calls
	% Fixed Insurance		% Other:

Personal Value Proposition

What is important to you?

While Founders Financial, Inc. is comprised of like-minded financial professionals, each is unique. Please share with us what specifically motivates you and what you seek professionally from a relationship with Founders Financial.

Historical Background of Your Organization
(Please provide a short overview of you and your organization)

Additional Information

What questions do you have about Founders Financial?

How did you hear about Founders Financial?

	Magazine Advertisement (Which magazine?)
	From a current Member (Please provide name)
	An Internet Search Engine (Which search engine?)
	Correspondence from Founders Financial
	Direct Mail from Founders Financial
	E-Mail from Founders Financial
	Other:

To establish your initial discovery meeting, please provide us with three convenient appointment options. We will be emailing you a meeting confirmation shortly after receiving and reviewing your request.

* Specific Date:		* Time of Day:
Specific Date:		Time of Day:
Specific Date:		Time of Day:

Shared Resources. Shared Values. - Founders Financial, Inc.