This confidential profile information will assist NFG consider and qualify you as a candidate for an Independent ‘Brokerage’ of NFG. If additional space is needed please attach a separate page with more details! Once completed please fax it back to 617-689-0707 for prompt attention. Thank You! Personal Information: Your Name: _____________________________________________________________ Home Address: __________________________________________________________ City: ___________________________________State___________ZipCode_________ Home Phone: ( )_________Work Phone ( )__________Cellular Phone: ( )___________ Fax: ( ) ____________________ E-Mail Address: _________________________________________________________ Educational Background: _________________________________________________ Do you belong to any associations, clubs, or organizations? _____ If so, tell us about them? _______________________________________________________________ ______________________________________________________________ Can you supply Character references? _____ Employment Information: (Your employer will NOT be contacted) Current Place of Employment? _____________________________________________ Position/Title: ___________________________________________________________ Present Salary: _______________________ Financial Information: Current funds available for investment in a new business: $____________ What is your yearly income goal? $ ____________________________ What is your current estimated net worth: $_____________________ General Information: Do you have any experience in the financial industry, sales, or management? If so, please explain:_______________________________________________________________ _____________________________________________________________________ Have you ever established a legal entity? __________ If so, what State and Legal Name of Entity? _______________________________________________________________________ What type: Corporation ___ LLC ___ LP ___ Non-Profit ___ Other: ____ Do you have a business web site? _____ If so, what is the domain? __________________________ Will you consider a partner for a new business venture? _____ If so, will this partner be active in the day-to-day operations? _____ How did you hear about our training & learning systems? ________________ If qualified, when would be prepared to start your business? __________________ This is a confidential evaluation profile. It does not represent a contract or warrant acceptance for any NFG programs. Print Name: _____________________________________ Signed: _________________________________________ Date: ______________________ Please fax to our consideration dept. for prompt attention @ 617-689-0707