Dr. Mr. Ms. First Name M.I. Last name
Your Title Company Name Company Address City State Business Phone E-mail
Gender: M F Date of Birth Certificate Expiration Date City State
* FPA requests home addresses for the purpose of legislative advocacy/ forwarding information
Number who work in your office/ firm location 1-5 6-10 11-50 51-100 101-500 501+ Your position Owner / Partner Independent Contractor Employee Other Broker-Dealer Affiliation (no abbreviations please) No Affiliation Affiliated with Registered Investment Adviser Information I am or my firm is registered with the SEC as an investment adviser I am or my firm is registered in the following states as an investment adviser: (separate by comma) I am excluded from registering as an investment adviser with the SEC or the states because: providing investment advice is incidental to my practice of accounting and/ or law I am employed by a bank providing investment advice is incidental to my business as a broker or dealer Other
Please send all mail to my: Home Address Business Address 1. I am not interested in receiving free quarterly practice management CDs (cds not available to student members) 2. I do not wish to receive the following e-mail newsletters from FPA: FPA This Week JFP Online FPA product announcements 3. FPA may develop mailing lists for other organizations. You can elect not to receive these mailings by checking this box.
I agree to abide by FPA’s Code of Ethics, and certify that: (check one only) I have not been accused in writing, or found in violation of the code of ethics of any professional credentialing organization of which I am a member. A state or federal licensing or regulatory body has not censured, fined, or reprimanded me, or revoked, or suspended my investment adviser, securities, or insurance license(s). I am not a defendant in a civil or criminal lawsuit. If a civil or criminal judgement has been entered against me in the past, it has been disclosed to FPA or its predecessors. OR (check if any statements apply) I have been accused in writing, or found in violation of the code of ethics of a professional credentialing organization of which I am a member. A state or federal licensing or regulatory body has censured, fined or reprimanded me, or revoked or suspended my investment adviser, securities, or insurance license(s). I am a defendant in a pending civil or criminal lawsuit: or a civil or criminal judgement has been against me that has not been disclosed to FPA or its predecessors. Note: Disclosure of legal matters is not an admission of guilt. I will complete details to FPA in a timely fashion. I understand that a finding of such violation may create a presumption that I have violated FPA’s Code of Ethics. For a full version of FPA’s Code of Ethics, please visit www.fpanet.org/ about/ethics.cfm
The Financial Planning Association is the owner of trademark, service mark and collective membership mark rights in: FPA, FPA logo and financial planning association. The marks may not be used without written permission from the Financial Planning Association. Copyright 2003
CFP®, CERTIFIED FINANCIAL PLANNER™ and federally registered CFP® (with flame logo) are certification marks owned by Certified Financial Planner Board of Standards. These marks are awarded to individuals who successfully complete CFP® Board's initial and ongoing certification requirements.
