About you and your team
1. First, middle and last name:(*)
Please type your full name.
2. Professional designations(*)
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3. Title(*)
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4. Name of your practice:(*)
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Your email address:
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Your phone number:(*)
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5. Are you a FINRA Registered Representative?(*)
Yes No - (Skip to Q7) Invalid Input
5a. Broker / Dealer firm through which securities are offered:
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5b. Broker / Dealer firm compliance:
I have reviewed the compliance guidelines and procedures of our firm for participation in outside activities and membership in professional organizations I have notified management at my Broker / Dealer firm of my intention to apply for Council membership Invalid Input
6. Are you personally subject to a disclosure reported or reportable in Question 14 of FINRA form U4?
No (Skip to Q 7) Yes (see 6a, 6b & 6c) Invalid Input
6a. If “Yes” to 6, please check all reported or reportable U4 disclosures (check all that apply)
14A – Felony 14B – Misdemeanor 14C – Regulatory action by the SEC or CFTC 14D(1) - Regulatory Action by other federal regulator, state regulator, or foreign financial regulator 14D(2) - Final order of state securities commission, state authority that supervises or examines banks, savings associations, or credit unions, state insurance commission, appropriate Federal Banking agency, or National Credit Union Administration 14E – Regulatory action by an SRO 14F – Professional Suspension 14G – Formal Pending Action / Investigation 14H – Civil Judicial Action 14I – Customer Complaints 14J – Termination for Cause 14K – Bankruptcy, SIPC, and Compromise with Creditors 14L – Bonding Compromise or Revocation 14M – Unsatisfied Judgement and Leans Invalid Input
6b. If "Yes" to 6, list date of action:
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6c. If "Yes" to 6, please describe:
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7. Are you a Registered Investment Advisor?(*)
Yes - State Yes - Federal No Invalid Input
8. Number of years you have been in the retirement plans business: (*)
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9. Website of your practice(*)
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10. Number of retirement plan advisors in your practice: (*)
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About your business
11. Are you responding for:(*)
Yourself Your team Invalid Input
12. Types of retirement plans served:(*)
401(k) 403(b) Money-purchase Profit-sharing-only Government 457 457(b) 457(f) 409(a) Non-qualified deferred compensation Traditional defined benefit Cash balance Other hybrid Others (please describe) Invalid Input
13. Number of plans served: (*)
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14. Number of participants in client plans (approximately): (*)
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15. Assets of retirement plans served(*)
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16. Year-over-year percent change in assets of retirement plans served(*)
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17. Scope of retirement plan services provided(*)
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18. Business activities other than retirement plans (*)
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19. Total revenue from Qualified Retirement Plans (INCLUDING corporate, not-for-profit, higher-education, private K-12, church Plans, government Plans but EXCLUDING IRA and public K-12) $(*)
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20. Percent of revenue from Qualified Retirement Plans (INCLUDING corporate, not-for-profit, higher-education, private K-12, church plans, government plans but EXCLUDING IRA and public K-12)(*)
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21. Revenue from business activities other than retirement plans $ (*)
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Client Reference
22. Organization name: (*)
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Name:(*)
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Title:(*)
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Phone number:(*)
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Email address:
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Plan type(s): (*)
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Plan assets: $ (*)
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Plan participants (approximately):(*)
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Recommendation
23. Name of the current Council Member recommending you for membership:
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Industry References
24. Please indicate below two references from the Retirement Plans industry in addition to the Council member who recommended you for membership.
First Reference
Name:(*)
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Title:(*)
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Firm or Organization:(*)
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Firm Category
Retirement Plan Advisor Advisor or B/D Firm HQ TPA Recordkeeper Investment Manager ERISA Attorney Trade Organization Service Provider to the Industry Industry Personality Invalid Input
Phone Number:(*)
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Email:(*)
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Number of Years you have known this person:(*)
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Second Reference
Name:(*)
Please type your full name.
Title:(*)
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Firm or Organization:(*)
Please type your full name.
Firm Category
Retirement Plan Advisor Advisor or B/D Firm HQ TPA Recordkeeper Investment Manager ERISA Attorney Trade Organization Service Provider to the Industry Industry Personality Invalid Input
Phone Number:(*)
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Email:(*)
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Number of Years you have known this person:(*)
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Thought Leadership
25. In what industry organizations or initiatives are you or have you been involved?
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26. Additional factors you would like the Council to take into consideration in the review of your application
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Council Involvement
(*)
By submitting this form, I agree to participate actively in the workings of the Council and to attend at least one in-person meeting and to participate in at least one committee of the Council every calendar year during my term. My client reference and industry references have agreed to be interviewed in support of my application. I understand that my membership may be revoked at any time.
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