Pacific Financial Application   PACIFIC FINANCIAL ASSOCIATION, INC. FEDERAL SERVICE CORPORATION ℅ 1606 W. Whispering Wind Dr., Phoenix, Arizona 85085 Telephone: (800) 595-2615 Fax: (623) 209-2626 Trust and Claims Administrative Contractor PACIFIC FINANCIAL ASSOCIATION, INC. ℅ FEDERAL SERVICE CORPORATION 1606 W. Whispering Wind Dr. Phoenix, Arizona 85085 Telephone: (800) 595-2615 Fax: (623) 209-2626 Trust and Claims Administrative Contractor

	Choose 1 Plan
	Plan #1 Plan #2 Plan #3* Plan #4* * On Approved Credit

	Company Information
	Legal Name Show exactly as it appears in OP-1 or on Broker's License
	MC# Write "Pending" if pending
	EIN# Write "Pending" if pending
	Form of Organization Sole Proprietorship Partnership Corporation LLC
	State of Organization 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
	Country of Organization United States Canada Mexico
	Mailing Address City 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 State Zip Code
	Physical Address City 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 State Zip Code
	Business Phone
	Fax#
	Cell Phone
	Email
	Current & Past Broker MC Numbers that any Principals/Officers have been affiliated

	Personal Information
	Name of Responsible Principal and/or Director Mr. Ms. Mrs. Dr. Prefix First Name MI Last Name Person responsible for signing Trust Agreement
	Home Address City 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 State Zip Code
	Home Phone
	Social Security Number
	Date of Birth Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
	By checking this electronic signature box, I affirm my identity as the person whose name is affixed as principal; I verify the above statementsare true and accurate; and, in the event we have requested Plan #3 or #4, I hereby authorize a personal credit inquiry. * Signed
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