ING Financial Partners
    909 Locust Street
    Des Moines, IA 50309-2899
    800-356-2906
(Items with an asterisk * indicate required fields)

*First Name:

*Last Name:

*Address:
 Building/Suite:
*City:
*State:
*Zip:
*Work Phone:
 Home Phone:
 *Email address:
 Who is your current broker-dealer:

 *How long have you been with
your current broker-dealer?

Not with a broker/dealer
0-3 years
4-9 years
10+ years

 *What securities licenses do you currently hold?

6
7
63
65
NONE
 66
26
24
22
OTHER

 *How long have you been securities licensed?

Not securities licensed
1-3 years
4-9 years
10+ years
 *How much did you produce last year in securities GDC?
YTD

 *What is your current product mix?

MF
VA
VUL
Brokerage
 Ltd Partnerships
Fixed Annuities
Traditional Life
OTHER

 *Do you engage in RIA activity?

Y Fee for Plans Assets under Mgmt
N    $

*What kind of representative are you?

Affiliated Representative (Agent of ING Equitable Life, ING Southland Life or ING Security Life of Denver)
Independent Representative
Associated with a Bank