| Name |
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| Address |
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| City |
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| State |
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| Zip |
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| What is most important to
you when doing business with a company?
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| Is there anything else you would like
us to know about you?
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| Have you already spoken with a DFW marketing associate? If yes, who?
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| Are you securities licensed?
Yes
No |
| If yes, must index annuity sales go thru your broker dealer?
Yes
No
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| What is Your Annual Commission/1099 Revenue?
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