Step 1 of 3 33% In partnership with PMG Legal Name(Required) First Middle Last Preferred First Name(Required)This field is hidden when viewing the formAgent Full NameEmail(Required) Enter Email Confirm Email Phone(Required)Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Physical Address(Required) Street Number and Street Name or P.O. Box City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are you currently with an RMJ partner agency?(Required)Please Select an OptionYesNoPlease select your Agency(Required)Please Select and OptionBest Financial PartnersBrookwoodPMGThis field is hidden when viewing the formPlease select your desired partnership rolePlease Select a Partnership RoleI am licensed or would like to become a Licensed Referral PartnerCommunity Connector (Refers potential clients as an unlicensed Referral partner)A Licensed Referral Partner can earn commissions on life insurance products and has the opportunity to advance by becoming securities licensed or registered as an Investment Advisor Representative. A Community Connector participates in a non-licensed capacity by referring potential clients or new business. In this role, they receive a 10% referral fee based on the management fee — only on investment assets, and not on insurance products.This field is hidden when viewing the formForm Key Filled?Hi . It appears you've already completed this first step. Please follow this link to move to the next stage. Employment History InformationAre you currently employed?(Required)Please select oneYesNoCurrent Employer Name(Required)Current Employment Start Date(Required)This field is hidden when viewing the formFinancial / Legal InformationThis field is hidden when viewing the formHave you ever filed for bankruptcy?(Required)Please select oneYesNoThis field is hidden when viewing the formIs it Pending or Discharged?(Required) Pending Discharged This field is hidden when viewing the formDate of Discharge or Pending Date Filed?(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This field is hidden when viewing the formAre you currently or have been involved in any legal action within the last 5 years?(Required)Please select oneYesNoThis field is hidden when viewing the formPlease Explain(Required)This field is hidden when viewing the formLegal Action Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 ReferencesThis is for required background check information.Please provide two (2) business or work-related references:Reference 1 - Name(Required)Reference 1 - Phone(Required)Reference 1 - Email Address(Required)Reference 2 - Name(Required)Reference 2 - Phone(Required)Reference 2 - Email Address(Required)How did you find out about us?(Required)Please select oneAn Existing Team MemberFamily or FriendsSocial MediaInternet SearchRadioOtherReferral Agent(Required)If one of our team members referred you, please select their nameSocial Security Number (no dashes please)(Required)This field is hidden when viewing the formUpline Rep EmailThis field is hidden when viewing the formUpline Rep IDThis field is hidden when viewing the formUpline Rep NameRMJ Rep IDBFP Rep IDBrookwood Rep IDPMG Rep ID
