New
Application
Change
of Information for Current Member
Name
Firm Name
Address (line 1)
Address (line 2)
City State
Zip Code
Telephone FAX
e-mail
Home Address
City State
Zip Code
Telephone
Which profession(s) are you affiliated with and for how long?
Insurance
Years
Banking Years
Bank Officer Yes No
Accountancy
Elder Planning
Planned Giving
Law Years
Year admitted to practice
State admitted to
Select Financial Services
Provider Note: If you are a select
financial services provider, job title and years in position must be
provided.
Job Title
Years in Position
Describe briefly how you are actively involved in the estate planning process. Include how long you have been doing this work.
Estate Planning Experience [Drag the lower right corner of the box to the right, to expand it.]
Professional Designations Held: Include all that apply.
Separate each designation with a comma (e.g. CLU, ChFC, CFP, CPA, JD, Esq., None)
Recommendations:
Two recommendations are required. One of the
recommending parties must be from the same profession as the applicant, and
the other recommendation must be from a current member of The Estate
Planning Council of Hampden County, Inc.(only one sponsor per firm)
Please indicate the name, profession, business address, telephone number,
and e-mail address of a local person in your profession.
Please indicate the name, profession, business address, telephone number,
and e-mail address of a Council member.
Date of application
I have read the information on the home page and understand the nature and
objectives of the organization. Yes
Thank you for your application/change of information.