First Name: *

Middle Name:

Last Name: *

Date of Birth: * ex. MM-DD-YYYY

SSN: * ex. XXX-XX-XXXX

Company or DBA:

Tax ID or EIN: ex. XX-XXXXXXX

Job/Position: *

School Name:

District: *

Email: *

Confirm Email: *

Password

Cannot contain your first or last name.
Must be at least 8 characters in length.
Must contain a number, special character, upper case letter, and lower case letter.

Password: *

Confirm Password: *

Cell Phone: * ex. XXX-XXX-XXXX

Alt Phone: ex. XXX-XXX-XXXX

Physical

Address: *

City: *

State: *

Zip: *

Same as Physical

Mailing

Address: *

City: *

State: *

Zip: *

Upline 1 Number: *

Upline 1 Percent: *

Upline 2 Number: *

Upline 2 Percent: *

How did you hear about us: *

Are you a US citizen? *

Yes No

Are you authorized to work in the United States? *

Yes No

Upload Proof (VISA..ect) *

Are you insurance licensed? *

Yes No

Do you have a health insurance license?

Yes No

Health Insurance License Number

Are you securities licensed? *

Yes No

What type of license? *

CCPA Privacy Notice

Background Information

Yes No

State: *

Resident: *

License Number: *

Texas Temporary License? Yes No

If yes, please explain:

Criminal History Questionnaire

Click here to download and review document.

Please review the above document before answering the following questions.

Applicant Name *

Yes No

If you answered Yes, provide city, county, and state of conviction and date and nature of the offense, along with sentencing information. Enter N/A if you answered “No” and this question does not apply to you. *

Signature *

Click here to download and review document.

I agree

Please check 'I agree' at the bottom of each disclosure after reviewing.

Signature *

Assessment

Signature *

ACH Deposit Information

Account Name: *

Account Type: *

Account Number: *

Routing Number: *

W-9 Information

Click here to download and review document.

1 Name (as shown on your income tax return)

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/estate

Limited Liability company. Enter the tax classification (C=C Corporation, S=S Corporation, P=Partnership)

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

7 List account number(s) here (optional)

Payment Details

Choose registration package:

Wholesale Agent Registration: Includes 10 PERA appointments and contracting

Wholesale Contracting Only: Includes wholesale carrier contracting fees and library of presentation materials for K-12 appointments

(Nonrefundable)

Due today:

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Coupon Code

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Card Type Card Number Expiration Date (mm/yy) Cardholder's Name Card Validation Code

Billing Zip

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As part of the Appreciation Financial System your registration fee has been waived for the first 45 days. If you submit two pieces of business through the back office during this time you will not have to pay a registration fee. If you do not submit two pieces of business through the back office within your first 45 days, you will be required to pay the registration fee of $225 to continue to have access to your Appreciation Financial back office and your myaf360.com account.

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Credit Card Number:

Amount: $

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