Membership Education Form

* Required fields

Name *

E-mail Address *

Home Address *

City *

State *

Zip Code *

Cell Phone *

Home Phone

Work Phone

Personal Website

Enroller Name *

Placement/Sponsor Name *

SSN or FIN *

Date of Birth *

Present Employer *

Position *

How long at present job? *

Do you know 5 people who would give you a personal reference? *

yes no

Do you currently have an insurance license, security license, real estate license, mortgage broker (or similar) license? *

yes no

Have you ever held any of the above licenses? *

yes no

Are you currently on active duty, a DOD civilian employee, retired from active duty, in the Reserves or National Guard, or left active duty service within the last 12 months? *

yes no

Have you ever filed bankruptcy? *

yes no

If so, when? Date / Discharge Date

Have you ever been denied a trade or professional license or had a trade or professional license revoked, suspended or restricted? *

yes no

Have you ever been charged with, convicted, or pled guilty or Nolo Contedere ("no contest") to a felony or misdemeanor (other than a minor traffic violation)? *

yes no

List 5 personal references - name and phone number *

I understand that this screening form is NOT a contract or application and that I have no contractual rights until I sign the agreement in the Licensing Pak. Additionally, prior to being entitled to any compensation, I must sign the Licensing Pak, obtain the necessary licenses, and complete required classes. Please initial. *

For processing this New Representative Screening Pak, I understand that as part of the licensing process, I will also be responsible for licensing fees, including state licensing fees, examination fees, and pre-licensing education fees. If applicable, I must complete Loan Origination class within 60 days to maintain loan officer contract, or any other position within the company. I must complete the Real Estate Salesperson course within 60 days. Please initial. *

Applicant Signature Authorization: I hereby authorize FTAMG to verify my past and present employment, order a consumer credit report, verify past and present mortgages, landlords, and personal references. Please initial. *

I authorize the draft of $19.95 for the monthly Membership Education Fee. Type your name to agree. *

Credit Card # *

Expiration Date *

3 Digit CVC *

Name on credit card *

Billing address *

City *

State *

Zip Code *

I have read and agree to the Privacy Policy *