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Agent Training Experience - Qualification Form
To see if you qualify to attend the The Annexus Group Agent Training Experience, please complete the following form:
(
*
= required field)
Contact Information
First name:
*
Last name:
*
Company Name:
Email:
*
Address 1:
Address 2:
City:
State:
- select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
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
West Virginia
Wisconsin
Wyoming
Zip:
Phone:
*
Annuity Production
Year-to-Date Annuity Production:
*
Prior Year Annuity Production:
*
Life Insurance Production
Year-to-Date First-Year Commissionable Premium:
*
Prior Year First-Year Commissionable Premium:
*
Securities Information
Are you securities licensed?:
*
Yes
No
If no, please skip to the Annuity Carriers section below.
Securities Registrations:
6
63
65
66
7
24
26
Year-to-Date GDC:
Prior Year GDC:
Annuity carriers currently appointed with:
Have you attended a previous Annexus event?:
No
Yes
I understand that air travel will be booked by Annexus Travel and billed to my credit card. I will receive full reimbursement at the event.
I would like to attend IRA, Inc. training prior to the ATE. I understand there is an additional cost for this training that will be at my expense.
I understand that I may be required to provide proof of prior/historical production to verify my answers above.
*
Required