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Platinum Membership

Terms:
Platinum Membership (Single Payment) – $749.99

Automatic Annual Renewal of $299.99

Please check here to agree to CSSCS’s Terms and Conditions.

Product Price: $749.99

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Account Information

First Name:

Last Name:

Email:

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Agent Number:

Resident License State: Current Designations:
CFP Certified Financial Planner
CFA Certified Financial Analyst
ChFC Chartered Financial Consultant
CLU Certified Life Underwriter
CLTC Certified in Long Term Care
Other:

Have you ever had a professional license revoked or suspended (i.e. insurance or securities license)?
Yes No
   If ‘Yes’, please explain: Have you ever had a complaint filed against you with any regulatory body?
Yes No
   If ‘Yes’, please explain: Have you or your company ever been refused for surety bonding?
Yes No
   If ‘Yes’, please explain: Have you ever been charged with, plead guilty to, or been found guilty of any crime, felony or misdemeanor? This includes, but is not limited to, convictions involving dishonesty, breach of trust or violation of any federal law (i.e. embezzlement, tax fraud)
Yes No
   If ‘Yes’, please explain: Has your employment and/or firm affiliation ever been terminated for cause?
Yes No
   If ‘Yes’, please explain: Have you ever been involved in any bankruptcy litigation?
Yes No
   If ‘Yes’, please explain: Are there any unsatisified judgements, liens or delinquent tax obligations against you or any business in which you were or are an owner, officer or director?
Yes No
   If ‘Yes’, please explain: I have read the questions above and answered them to the best of my knowledge.

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