Date:

Personal Information

Full Name: Nominated By:

Home Address City State Zip

Home Phone # Date of Birth Email

Professional Information

Company Name

Business Address City State Zip

Business Phone # Business Fax # Website Address

Email Occupation

Area of Specialty/Years of Practice:

Professional Services Provided:

Degree(s)/Date of Acquisition:

License(s)/Date of Acquisition:

Certifications/Date of Acquisitions:

Background Information

If you answer, "Yes" to any question, please provide a complete explanation in the box provided below.

Yes No
1. Have you ever been found guilty of, or pled guilty or nolo contendre to any crime (misdemeanor or felony) including, but not limited to, crimes involving dishonesty or breach of trust or are you presently under indictment?

Yes No
2. Have you ever had any professional and/or occupational license revoked or suspended by any regulatory authority and/or governmental agency, or have you ever had an application for any professional and/or occupational license denied by any regulatory authority and/or governmental agency?

Yes No
3. Have you ever had any complaint filed against you with an employer, regulatory authority and/or governmental agency or do you anticipate one being filed?

Yes No
4. Have you ever been subject to any regulatory, governmental or disciplinary action?

Yes No
5. Have you ever been terminated for cause by any private or public employer?

Yes No
6. Have you ever been involved in any civil litigation, or do you anticipate being named as a defendant in a complaint?

Yes No
7. Are there any judgments or liens (including State or Federal tax liens) against you?

Please check each box in acknowledgment and understanding of the following:

I certify that I have completely reviewed this Cashing Out Advisory Council™ membership application, and that I have answered all questions fully, honestly and to the best of my knowledge and belief. I also certify that I understand and acknowledge that submitting false, misleading or materially incomplete information may result in membership refusal or revocation.

I certify that I will promptly update my membership application whenever there is a modification in any of the information that I have provided. I also certify that I understand and acknowledge that any amended application information may cause a re-evaluation of my membership status. In addition, I certify that I understand and acknowledge that continued membership in the Cashing Out Advisory Council™ is contingent upon my compliance with all present and future COAC™ membership policies.

I certify that I have signed and submitted the COAC™ Code of Ethical Conduct and that it is my intent to fully adhere and apply these pledges to my daily practice in the service of my clients. I further certify that I understand and acknowledge that any deviation from these ethical precepts is a justifiable ground for expulsion from the Cashing Out Advisory Council™.

I certify that I understand and acknowledge that in order to maintain the integrity of the Cashing Out Advisory Council™, membership is strictly by invitation-only and solely at the discretion of the COAC™ Membership Committee, which has absolute and exclusive authority over all membership decisions. I also certify that I understand and acknowledge that membership in the COAC™ may be refused and/or revoked at any time and for any reason and that membership refusal and/or revocation is final and without recourse. In the event of membership refusal and/or revocation, I certify that I agree to hold harmless the COAC™, its principals and employees. I further certify that I understand and acknowledge that the COAC™, its principals and employees, shall not be held liable if membership in the Cashing Out Advisory Council™ is refused and/or revoked.

To sign your application, please enter any combination of alpha/numeric characters in between forward slash (/) symbols. For example, applicant John Doe could sign as: /johndoe/

Signature: Name of Signatory:

Date Signed:

Note: A secure connection will be used in the submission of your application.

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