Financial Advisor Profile
All responses will be held in strict confidence and not shared with or sold to any outside parties
Please fill in all blank sections. If not applicable, write “N/A”
   

 Section One
 Contact Information
 Name:  First  MI  Last  Nickname
 Social Security #   - -
Birthdate
CRD #
Place of Birth
Agency Name
Physical Business Address
City State Zip
Phone FAX eMail
Address to Receive Mail
City State Zip
Residence Address
City State Zip
Phone FAX Cell
Married Yes No Spouse’s Name 
 
   

 Section Two
 Securities Registration
 Please select all relevant information
Initial FINRA Registration  Transfer of Current Licenses
 Current Securities Licenses Held
   6   7   24   26   63   65   66   None   Other  
Use table in Section 4 to indicate state(s) in which you require Securities Registration (RR Column).
If not currently registered with a broker/dealer, when will your license(s) expire?
 
   

 Section Three
 Solicitor Registration
Special Designations
CPA   CFP   ChFC   CLU   CSA   CFA   PFS   CIC   EA   RIA
Were you registered as an IAR with a previous investment advisory firm?  Yes No
If yes, give dates: States:
Use table in Section 4 to indicate state(s) in which you require Investment Advisor Representative
Registration (IAR Column)
 
   

 Section Four
 State Licensing/
 Registration
Check the appropriate box(es) below indicating states in which you hold variable insurance
licenses (INS). Also check the appropriate boxes to indicate in which state(s) you require
securities (RR) and IAR registration.

   RR       IAR       INS     STATE
 Alabama  
 Alaska  
 Arizona  
 Arkansas  
 California  
 Colorado  
 Connecticut  
 Delaware  
 Florida  
 Georgia  
 Hawaii  
 Idaho  
 Illinois  
 Indiana  
 Iowa  
 Kansas  
 Kentucky  
 Louisiana  
 Maine  
 Maryland  
 Massachusetts  
 Michigan  
 Minnesota  
 Mississippi  
 Missouri  
 Montana  
   RR       IAR       INS     STATE
 Nebraska  
 Nevada  
 New Hampshire  
 New Jersey  
 New Mexico  
 New York  
 North Carolina  
 North Dakota  
 Ohio  
 Oklahoma  
 Oregon  
 Pennsylvania  
 Rhode Island  
 South Carolina  
 South Dakota  
 Tennessee  
 Texas  
 Utah  
 Vermont  
 Virginia  
 Washington  
 Washington DC  
 West Virginia  
 Wisconsin  
 Wyoming  
 
   

 Section Five
 Relationship
 Information
I intend to engage in Personal Sales or Office Support Services
How did you learn about PlanMember?
Current Broker/Dealer
Other Broker/Dealers in past 5 years
If you are affiliated with an Insurance agency, which one?
If you are affiliated with an agency, who are your two immediate upline managers?
If you are affiliated with an Independent Marketing Organization, which one?
Are you subject to any restrictive employment contracts? Yes No
If Yes, please explain:
Besides Securities and Insurance, what other background or careers have you had?
What other Broker/Dealers are you considering?
What two things about your current Broker/Dealer prompt you to seek a change?
1.
2.
What are two top needs you have in a new Broker/Dealer relationship?
1.
2.
When or what date would you like to affiliate with PlanMember?
Do you consider your financial practice: Full-time Part-time
When do you plan on retiring from your financial practice?
Upon retiring, would you be interested in receiving long-term residual income from the sale or
transition of your financial practice? Yes No Maybe
If it is appropriate for your clients, would you be interested in offering a competitive turn-key
managed account program that can provide you with long-term residual income?
Yes No Maybe
 
   

 Section Six
 Gross Dealer
 Concession
What was your gross securities income (not including fixed insurance) for:
trailing 12 months: $    2009: $ 
What was your gross income for fixed insurance for:
trailing 12 months: $    2008: $ 
 
   

 Section Seven
 Investment
 Business
 Activity
Current Business Practice
Total # of Clients        Years in Financial Services  
Total # of Qualified Plan/403(b) Clients  
# of Deferring Qualified Plan/403(b) Clients  
% of Business is Qualified Plan/403(b)  
# of School Districts  
Total Client Account Balances
Fixed Annuities: $ Variable Annuities: $
Mutual Funds: $ Other: $
Managed Accounts: $ REITS / L.P.S:: $
   

 Section Eight
 Common Remitting (if applicable)
Do you use any Common Remitting services (ie: do any clients have salary deferral contributions
that flow or go to any company or organization, other than direct to the mutual fund and/or
variable annuity companies?) Yes No
  If yes, Common Remitting is needed for:
   # of School Districts/Employers      # of Vendors      # of Clients  
When you enroll a client for salary deferral, do you use a payroll slot(s) other than going direct to mutual fund and/or variable annuity companies? Yes No
Does your current Broker/Dealer forward client funds to mutual fund and/or variable annuity companies? Yes No
Does your current Broker/Dealer (or any BD affiliate) process any of your client’s
salary deferrals? Yes No   
 
   

 Section Nine
 Products/Services
 Mix
What percentage of your gross income is the following?
Mutual Funds  Variable Annuities  Fixed Annuities 
Fee Business  Equities (stocks)  Financial Planning 
Tax Preparation  Group Annuities  Other (describe) 
If you are not yet building a fee-based business that provides residual income, are you open to being coached and using tools to assist you in building a fee-based financial enterprise?
Yes No Maybe   
What other sources of income do you have? (i.e. outside business activity)  
Do you provide financial planning or hold yourself out as a Financial Planner (ie: either complimentary or fee for service to establish long term financial goals through investments, asset allocation, risk management, tax, retirement and/or estate planning; debt consolidation)? Yes No
What methods do you or will you use to build your business?
Have you ever or do you plan on advising clients to take mortgages on their home to purchase insurance or securities products? Yes No
Have you ever or do you plan on advising clients to reduce their debt by taking 403(b) loans on their securities or insurance accounts? Yes No
Do you now or do you plan to sell limited partnerships, debt consolidation programs, viatical settlements, life or structured settlements, promissory notes, hedge or futures funds, pay phones, venture capital, etc.? Yes No
If yes or maybe to any of the above, please explain:
   

 Section Ten
 Reportable Events
Do you have any disciplinary history? Yes No Maybe
Is there any reportable matter(s) that you are, have been, or believe you could be subject to that has not been disclosed on your FINRA Form U-4 or any state's department of insurance?
Yes No Maybe
Have you ever filed bankruptcy or entered into a compromise with creditors? Yes No
Have you ever plead guilty to or been convicted of any misdemeanor or felony? Yes No
If Yes to any of the above, please provide details
In the last 5 years, have you had or do you now have any current or pending judgements or liens or law suits against you? Yes No Maybe
If Yes or Maybe, please provide date and details
   

 Section Eleven
 Outside Business
 Activity Disclosure
If you are employed by or receive compensation from another business entity or individual, you are engaged in an outside business activity outside the scope of your employment or proposed employment with PlanMember Securities Corporation. Under FINRA Conduct Rule 3030, persons associated with PlanMember are required to report any kind of business activity (insurance or otherwise) they engage in away from their firm. Furthermore, it is the policy of PlanMember Securities Corporation that any such outside business activity must be approved by the Compliance Department in writing prior to engagement in said activity. If you are engaged in any outside business activity, including Fixed Insurance, you must complete an Outside Business Activity Form prior to registration.
 
I have Outside Business Activity (including Fixed Insurance) to report Yes No
Nature of Business
  Is this business investment related? Yes No
Your Position/Title or Relationship
 
   

 Section Twelve
 Signature and
 Pre-Hire Consent
I, the undersigned applicant ( am ) ( am not ) currently registered to sell securities with another broker/dealer, the FINRA, and the state(s) in which I intend to make sales.

I hereby acknowledge, represent and agree that I shall make no solicitations or sales until I am notified by PlanMember Securities Corporation that I am fully registered by both the FINRA and the particular state(s) in which I intend to make sales. This includes the period between my resignation from the broker/dealer with which I am currently registered and the date PlanMember Securities Corporation notifies me that my registration transfer is complete. I realize that what may constitute a solicitation may include merely my mentioning or suggesting to previous clients, existing clients or prospective clients to give consideration to investing in a security, and may also include my referring any clients to registered representatives of PlanMember Securities Corporation or any other broker/dealer, depending upon the particular state law. I have read and understand the applicable laws of the state or states in which I operate or intend to operate, and I am aware of the activities that would constitute a solicitation in such state or states, and will comply with the provisions of such laws. The signature below authorizes PlanMember Securities Corporation to access the FINRA Central Registration Depository to review my disciplinary history.

Further, I acknowledge and understand that any product or business affiliation outside the scope of PlanMember Securities Corporation must be approved by the Compliance Department in writing prior to my participation. Furthermore, I understand that the purpose of this form is for disclosure only and does not constitute approval of any outside business activity cited above. I also understand that I have an obligation to immediately notify the Compliance Department if any information provided above changes.

I authorize PlanMember Securities Corporation to investigate my background, including, but not limited to, the information contained in this business profile, the review of Credit Bureau Reports, CRD records, IARD records, and any other databases/services that provide publicly available information and hereby release PlanMember Securities Corporation, its officers, directors, employees, and affiliates, from all liability for any damages that may result from obtaining or furnishing the same.
Signature  Date:  September 08, 2010
 
  Financial Advisor Profile 070410.1498