	Instructions: Please answer each of the questions below. Your responses will be used only by Affiliated Marketing Group and not shared outside of our office. Please allow 24 to 48 hours for our staff to activate your account.

*	First Name:
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	Date of Birth (mm/dd/yy):
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	Street Address:
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	Home Phone:
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*	E-Mail Address:

	Resident State:
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	CRD Number:

	Please specify those lines of business you are actively selling:	Annuities Life LTC Disability Securities Health


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