Agent Application

I have furnished the information herein, which is true and complete. Any false or incomplete information in this form will be grounds for immediate termination of my appointment and contract(s) with Allied Trust at its sole discretion. I further understand and agree that:

• I will maintain, at my own expense, necessary office technology to access and use Allies Trust’s electronic communications, illustration and enrollment systems, and other software applications, and to use only the most current version of this software available from Allied Trust.
• I will be required to participate in Allied Trust’s training as applicable and agree to fully participate.
• I will be familiar with Allied Trust’s production before I promote them.
• I will comply with all Allied Trust guidelines, policies and procedures, and will abide by all laws and regulations.
• I will notify Allied Trust within thirty (30) days if I or any employee, associate, officer, director, principle, or other representative of my business is convicted of a felony.

Under penalties of perjury, I certify that (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, and (3) I am a U.S. person (including a U.S. resident alien). The IRS does not require your consent to any provisions of this document other than the certification required to avoid backup withholding.