I r--.r E TrrntamcricaOclidcotrl Lif.

Irrdrrncc Company CONTRACTATPLICAIION FOR:

E TRANSAMERIC"q,
G. IT.SUn.ANCE
6.IN1I8STMENTGROTJP
Homc Office CcdarRaoids.lA 52499
AdmidstrerivcOffice PiO.box 419521
Kense!Gry, MO 64141-6J21
E Ag€[t Cqrtraci (ftl-tin Carce(Ag.nt)
E IadepeadentProducerContract Frokcr)
I Tran*ocrica Lifc lrrur.nc. Compeny El SalesDirector {epp[c,riotrrcqdredftr
HomcOffic.: Ccd.r R.pids, tA 52499 individu.li mt or.raidy codrrect d drh
AdminisEtiv€Oflicc:PO. Box4t9521
Kans$ City,MO 64141-6J21 Trintiddic.l

Requesting GA Name: Of6ceID: .-..-..'-................._

Date:_ l_l

Applicant is: O An Individual O A Corporation O A Partnership

I am requesting an agreementwith:

E Transamerica Occidcntal Lifc Insurancc Company (TOLIC - Fixcd Life)

E Tlansamerica Life lnsurancc Company (TLIC)
I am also requesting the company(ics) makc application(s) to thc Deparunent(s) of Insurancc for the issuanceof a licenseand/or
appoinment thc sol.icitation of applications on behalf of the company(ies). I understand that I may sot solicit
-authorizing
applications for tie compaoy
(PleasescePart VI for additional provisions rcgarding al4rlic.nt's agreemcnt to bc bouud by the Agent aodl or IPC conrract or
contracb).

Section A: (If applicart is an ind.ividual, cooplcre secior A only.)

Last Name: First Name: Middle Name:

Social Security Number:-------:----------:--. Do you plan to markct using a DBA? E Yes O No If so, pleaseprovide
the supportitrg documentation, i.c., approval of required lurisdiction(s), DBA Name:
pace six for gcneral
(SeePage sctr€ral insttuctions conccruing
conccruine Taxpayet
TaxDaver Ideotification (T
Nunbet (TIN)
Idedtiftcetion Nuober IDforE tiotr.)
Home Phoae #: ( L-- Ccll Phone #: ( Pagcr#: (
BusinessPhone #: ( ) Fax#: ( ) Email Ad&css:
tr M! E Mrs. ! Mg D.O.B.-/- /_ Drivcr's License# Statc:
BusinesVAlternate
Addrcss:

city Zip Code

Ciry Zip Code

Strcct CirY Stat€ Zip Code

How long at this residencc addrcss? -Ycare Months If lessthan five ycars, pleaeeprovide past five years below:
-
ResidenceAddress: Street CitY Stete Zio Code

Section B; {If applicantis e corporatior or partncrship,complctescctionB only).

Parmershipor CorporateFirm Name:
Do you plan to do businessas a DBA? tr Yes n No If so,please provide ttresopponing aoclffe'iAc*g,T.I,Tf,F3fft8l*t'
required jurisdictiou(s), DBA Name: , and EIN for DBA if acquired -
(Seepage six for gcneral instructions conccrning Taxpayer Identification Number (TIN) Idormation)

TOA556-1105 Pagc1 of 8
illlililtffiililtil
'D C 1?r
BusinessPhone#: ( ) Fax#: ( )- EmailAddress:
Address:Street
Business/Alteruate City Zip Code

Mailing/Primary Ad dtes* (if differentftom BushessAddrcss)

Name of person who will sign as principal of this organizatiou Titlc

(PleasccompletePan Il SectionA for ptiocipal)

(A SolicitorApplicetio! form TOA 560,rnurt be complercdfor edditioml priacipds audeigdrg of6ccrs,)
For corporatiodparmership, givenamesof all ofliccrsandpriocipals,andtheir titlcs, If aeccssarnplcasccotrtinucon a seperateshectof papcr.
(Plcasccomplaea SolicitorApplicationform for cachpcrsonwhowill solicitTraaramcicabusiness on bchalfof thccorpo..tion or p.rtncrsf,ip.)

NAME TITLE NAME TITLE

1) How long have you bccn an insurance agent or broke!?

Below, pleaselist the compa es that you currently reprcsent:

Company Name: Effective Date:

2) U this ioloruration covcrs lessthan fir'e years, pleaseprovide details of employment history to completc the five-yeaf period
in the following section.

Employer Address Position

3) Are you row or have you ever bcen contracted with any Transamerica companyl Q Yes ONo
If yes,with which agency?

4) Pleaseprovide a copy of your individual ard/o! corpolate lcsidcnt Iiccnse(and/or a copy of your Letter of Certificatiou, if
yolu resident statc requircs such).

5) Do you plan to solicit Transamcrica busincssin othcr iurisdiction? O Yes E No If so, arc you clrrendy licensed in
thosc states? DYes E No If yes, plcaseprovide details i-ocluding copy(ics) of liccnse(s)for tho6e states.
(Ple4sepfouide copy(ies)of non-tesidentlkease(s)dnd.setd non-residentf..s). lf. \ot, please be alr'ale that no solicitation of
businessmay occur until you arc properly liccused and appointed as rcquired in those states.

5) Do you plan to have any of your employccs solicit Traosaurcrica businesson your behalf? O Yes D No. If so, please
have cvcry employeesoliciting Transarncrica busincsscomplcte a Solicitor Application form.

TOA 556-'t105 Page2 ot 8

 The following questions must be aaswered by the applicaoL ff the applicatt is a corporation or paruerqhip, tle questious
apply to the fiIm and to each of its priocipals and officers. I/ yot ansuet YES to ary questions, pbase @n plcte alctaik dnd
4lat diaL on a wafltu sheet of pqer anil proaide seppotting doaonsntotion-

1) Have you ever bccn convicted of, pled guilry or no contest to a felony o! misdcmeanor? D Yes ENo
Note: you iray orrritrflisdemeanotcoivictions for possexioxof metijuanethat occvrteil mote
than two yea6 dgo.

tt Is there any criminal indictment or criminal proceeding pending againet you? O Yes ENo

J' Have you, or any businessof which you were or plesently are a principal, been involved in a DYes QNo
bankruptcy action within the last sevenyears? (If YES,pleaseattach detailedexplanationand a copy
of the dischargepapers,if applicable.)

4l Have you been a plaiatiff or defendant in any court proceeding within the last sevenyearsl Q Yes DNo
Nota Yor nay onit actiorLtintobhg tnattet of family laut,

5) Do you presently have, or have you ever had, aoy professional designations or membe$hips in fl Yes O No
industry organizationsl (If YES,pleaseprovidea list of suchdesignationsor ocmbetshipsandindicste
datesof activity.)

6) Have you ever had any license denied, suspcndedor revoked, or bccn the subject of a disciplinary E Yes QNo
actiotr which resulted in a fine, penalry or restricted liccuse status? "LicenEe" shall include the
following: a liccnse issued by a state insurance department, a state securities agency,the NASD,
the SEC, or any other regulatory agency (or any other professional licettse or d,esignation),

7) Have you ever been discharged, or have you ever beenrequested to rcsign, from any enployment? El Yes tr No

8) Have you ever had any company appoioturents involuntadly terrninated? O Yes ENo

9) Are there any outstanding judgments, liens, or gamishments against you, or any businessof which EYes QNo
you wele o! pfesently are a principal?

10) Do you have urresolved matters pelding with the Intemal Reyenue Serviceor other taxing flYes ENo
authorities ?

1 1) Does any insureg general agcut, agcnt, or broker daim you are indebted to it for unpaid prerniums, E Yes E No
mishandling collateral, lossessustained, or any other rcason?

12) Has any EBcO carricr denied, paid claims on, or canceledyour coverage? E Yes 0No

13) Are you currendy covered under an EBcO policy? If ycs, give details on the next line. E Yes ENo
(Pleescprot,ide copy of policy face page or ccfiificate.)

Namc of Carrier:
CoverageExp. Date -l_ l_ Amount of Coveragei_

1.4) t{as a bonding or surety company denied, paid out on, or rcvokcd a bood for youl Q Yes ENo

15) llave you everhad a bond declinedor canceled? OYes ENo

16) Are you currendy bonded? OYes ENo

TOA 556-1,t05 Pag. 3 of 8

 Notice to PersonsApplying for SalcsRcpres€trtatiye Positions
with Transamerica Occidental Lifc Iqsuralce Compatry and Tiansamcrica Lifc Insurance Cornmpany
Federal law requires you be advised that in connection with your application to rcpres€trt Transamqica Occidental Life
Insurancc Compaay and Transarncrica Life Inswaace Company (referred to as 'Transamerica" ) for the pu4rose of selling its
products, a consumer rcpon andlor investigative consurner repon may bc prepared whercby information is obtained through
credit reponing agenciesand./or pcrsonal interviews with your ncighbors, friends, or others with whom you are acquainted.
Such reports are usually pan of the processof evaluating suitability for a salesrepresentativeposition. Inquiry may bc made
into your character, general rcputation, pcrsonal characteristics, and modc of living and credit information. It is possiblc that
a representativeof a firm employedto make suchreportsmay call upon you rn person.

You have a right to rcquest disclosure of the nature and scope of the investigation upon wrirten request to our !{ome Office
made within a reasonable time after the receipt of this notice. A summary of your rights undcr thc Fair Credit Reporting Act
is attached hercto.
Authority for Relcascof Information
To Whom It May Concem:

I hereby authorize Traruamerica or its legal representative to obtain any information ftom former or curcnt cmployers,
criminal justice agencies,consumc rcporting agencies,or individuals, rclatiog to my activities. This information may hclude,
but is not ligrited to achievement, performance, attendancg pcrsonal history c.edit and conviction records. I hereby dircct
you to releasesuch information upon requestto Transamerica or its legal reprcscntativc. I undcrstand that Transamerica or its
lcgal representativc may bc rcquircd by law to releaseinformation obtained to govemrnent agencies.

I herebyreleaseall personsand entities,including recordcustodians,from any aod all liability for damagesofwhatevcr kind
or nature which may at any tirnc result to me on account of compliance, or any anempts to comply, with this authorization.
A photocopyof this relcascshall be as valid as the original.

I havc thoroughly revicwed this application and have answcrcd all qucstions to the best of my knowlcdge. By signing below,
I hcreby agree to all mattcrs 6ct fortb above and bclow, including, a mutti-company assignment of commissioni set-forth in
Pan VItr and dre acknowlcdgcmcnt authorizations and releaseseet fonh in Pan V-

I hereby agree that if and when any or all of the companies issuc to me any Conuact(s) for which I hereby apply, I will be
bound by such Conuact{s) (lndepcndent Producer Contract on form number CNI-550 for TOLIC, or Ageni CLntract on
form numbcr CNI-500 for TOLIC, or on Non-lndividual Ageot Contract form nu-ErberCNI-525 for TOtlC. I understand
that my supervising office has specimen forms of the Crcntract(s) on file and I havc had the opporrunity to review such
Contract(s). My submining to the company any application for an insuraoce policy or annuity contract shall con$titute my
agr€ement to such Contract(s), and all of the tens, cooditions, and provisions set forth thctcin. I acknowledge that by
signing rhis Conrract-Application and by submining aoy such insuranceapplication for an insulance policy or annuiry conuact,
I have so agreed to the Contract(s) and no {urther signature by me shall be necessary.

I havc becn provided with pagesfive (5) through ten (10) of this application, for my records.

Applicaot Signature Date

GA Signature Datc

TOA556-110s Pagc4 of 8
 The Applicant, hcreinafter called the Assignoq for value rcccived, assigosto Transamerica Occidental Life Insurance
Compaly aad TransamcricaLife lnsurancc Cmpang and to any othcr company which is a subsidiary or a6liatc of Trauamerica
Occidental Life Insurancc Company- Transamerica Corporation or Transamcrica Insurance Corporation of Califomia,
individually and collectively rcferred to herein as Assigncc or Assignecs,their successorsend assigns, all of thc Assignor's
rightr, title and interest in and to any and all commissions and other compensation of any nature whatsoever now due and
payable or hereaftcr to bc€ome due and payable under the terms of any and all agencycontracts and commission agrccmcnrs,
now or hcreafter existing, bctwcen thc Assignor and each Assignee,

This Assignmcnt is given to securethc payment of any presertt or future debit balancein the Assignor's account with cach
Assignee and any othcr prcsent or future indebtednessof thc Assitnor to each Assignee.Notwithstanding anything to the
conEary i! any othcr agreement heretofore or hercafter cxccutcd betwecn the Asignor and any Asigace, it is expressly
ageed, but lot by way of limitatioo, that the foregoing includcs repayment of advancesagainst commissions heretofore or
hereafter giveo to the Ascignor by any Assigneetoward repaymcnt of such advancesand iqterest,

This Assignment shall be subiect without exception to thc tcrms, limitatioos and conditions of said ageocycrntracs aad
commission agreements and to all rights thereunder of thc Assignccs, their successorsand assigns. Notwidrstanding this
Assignment tbere is rcscrvcd to cach Assignee,is successorsand assigns,the right to offret against said commissions aad other
compeosation any and all advancesfrom dre Assigneesto thc Assignor and any indebtednesswithout cxception ofthc Assignor
to aoy Assigneenow existing and such other and futurc indebtedriesswhich any Assigncc, its succ€ssorsand assigns,would
have beenauthorized to dcduct ftom or of6et against said commissions or othcr compensation payablc to thc Assignor if this
Assignmcnt had not bc€n madc, If the Assignor is or hercaftcr becomesinsured under or covered by any group insurance,
pension,retiremeng defcrred compensationor other bencfits plan, or any policy plan providing errors and omissions protectioa
or simi.lar insurance, provided by any Assigaeefor its agents o! utilizing any Assignee'saccounting facilitics, thc Assignor
reservesthe right to authorize any Assignc€,or to continue any existing authorization, to deduct from ssid commissions and
othe! compensation the Assignorb premium or other coutdbutions to or for suchplans and policies and to authorizc incrcascs
in thc amount of such dcductions.

It is the intent of this Assignmcnt that aay Assignce rcceive and retain the commissions and other compensation which
are the subiect of this Assignment only to tie extent neccssaryto seculereFryment ofany present or futurc dcbit balancein the
Assigootb account with such Assigneeand aay o&er prcscnt or fufure indebtednessof 6e Assignor to etrh Assignce.Thcrcbrg
notwithstatding anything to thc contrary herein, cach Assignceis hereby authorized and directed to pay all commissiqns and
other compcnsation in thc Assignor's account witb such Assigncc to the Assignor for his/her own usc and pu:rposeunlessaod
qtil an Assigncc dctermines that it is necessaryto cnforcc thc termc of this Assignment to plotect its inierect itr sucb debit
balancesaud ottrer indebtedncsswithin the intent of this Assignment.

Each Assigneeir hereby authorized and directed to pay all comrnissionsand otler compeusation helcby assigneddirectly
to any other Assignee, unless aod until ir receivesa written releeseof this Assignment.

All Assigneesare hereby authorizcd to lcceive any moneys now due aud payable and which may becomc due and
payable uader the above indicatcd agencycontracts and cosurission agrccmcnts. The Assignor hcrcby ratifies any acts that
any Assigneemay rnake in connection with this Assignnent.

It is istended that the provisions of this Agreemetrt be construed irr the same manner as if thc Assignor bad executed
separateassignpeats ia favor of each of rhc companies that consdtutc er Assigneehsreunder.

TOA56&1105 P.gc 5 of 8
 Under currcnt tax laws, you arc required to give us your corrcct TIN (either a Social Security Number (SSN) or Employer
Identification Number (EIN).

The lnternal RevenueServices(IRS) usesthe TIN for identification purpoeesand to hclp verify the accuracy of your tax
rcturn. You must provide your TIN whcth€r or trot you arc lcquLed to filc a tax rcturn.

Transamerica must gcncrally withhold 31ol" of your commission payments if you do not givc us a correct TIN. Certain
pcnalties may also apply. Following arc some general guidclines:

a Individuals: If you are an individual, you must provide the name shown on your social security card.
Howcveq ifyou have charged your last na.me(e.g.duc to marriege) without informing thc Social Security
Administlation, pleaseeotet you! fust name, the last name shown on your social security card and your
new last name.

. Sole Propri€to(s: You (the owDer) must provide your individual aame al it appea$ on your social
security card. You may also provide your "doing businessas" narne. You may use eithcr your SSN or
EIN. Show the name that appcars oa your social securiry card and the busincssname as it was used to
apply for your EIN or Form SS-4. Pleasenote rhat usc of aa EIN may result in unnecessaryIRS noticcs
being sent to Transamerica by thc IRS.

. CorPontion aod Parbcrships: Provide us the namc and EIN of the partnership or corporation-

lf you do not have a TIN, you must rcqucst onc ftom the Social Security Administration by using Foro SS-4(for EINs)
or SS-5(for SSNsl.

tl Additiolal inforrnation to any "Yes- answers

,l Copy of currcnt resident licensc
O Copy of nou-resident Ucense(s)
tl Supporting docunentation, i.c., court records
,l Voidcd check or savingsdeposit slip for Auto-Pay

TOA556-1I05 Pagc 6 of 8
 Pare informacion en esp6tol, nisi? unttro.ftc.goulaedit o esaibe a Ia FTC Con*mu ResponseCetrt4
Room 730-A 600 PennsyhtaniaAae. N.W,, Washington, D,C. 20580

6 5.-'-'sy of Your Rights Under the Fair Credit Reponing Act

The federal of Your Rights Under the Fair Credit Reporting Act (FCRA) promotes the accuracy,faimess,
and privacy of information in the files of consumer reporting agencies. There are many types of consumer
reporting ag€ncies,including credit bureaus and specialty agencies(such as agenciesthat sell information about
check writing histories, medical records, and rental history records), Here is a summary of your maior rights
under the FCR.A- For more infonnatiou, includiag iaformation about additional rights, go to www.ftc.gov/
credit or write to: ConsumerResponseCenter, Room 130-AoFederalTrade Commission, 500 PeonsylvaniaAve.
N.W., Washington,D,C. 20580.

. You must be told if hformation in your file has becn used againstyou. Anyone who usesa credit report or
another type of consumerrepon to &ny your application for credit, insurance, or employment- or to take
another adverse action against - you must tell you, and must give you the name, address,and phone
nurnber of the agencythat provided the information.

r You have the rigbt to know what is in your file. You may requestand obtain alt the information about you
in the files of a consumerreporting agency(your 'file disclosure"). You will be required to provide proper
identification, which may include your Social Security number. ln many cases,the disclosure will be frec.
You are entitled to a free file disclosure if;
r a person has taken adverseaction against you becauseof information in your credit reporq
. you are the victim of identify theft and place a fraud alen in your file;
r your file contains inaccurate information as a result of ftaud;
a you are otr public assistance;
. you are unemployed but expect to apply for ernployment within 60 days.
In addition, by Scptember2005 all consumers will be entitled to one free disclosure every 72 months upon
request from each nationwide credit bureau and ftom nationwide specialty consumer reporting agencies. See
www.ftc.govlcredit for additional information.

o You have thc right to ask for a credit score Credit scoresare numerical sunnraries of your credit-worthi-
nessbasedon information from credit bureaus. You may request a credit score from consumerreportirg
agenciesflat create scorcsor distributc scoresusedin rcsidential real property loans, but you will have to
pay for it, ln some nortgag€ transactions, you will receive credit score information for &ee from the
mortgage lender-

. You have the right to dispute inconplete or inacclratc information. If you identify information in your file
that is incomplete or inaccurate, and report it to the consumerreporting agency,the ag€ncymust investigate
unlessyour dispute is frivolous. Secwww.ftc.gov/credir for an cxplanation of dispute procedures.

a Consumer r€porting agenciesmust conect or delete inaccurat€, incomplet€, or unverifiable information,

lnaccurate, incomplete or unverifiable iaformation must be removed or corrected, usually within 30 days.
However, a consuner reporting agencymay continue to report information it has verified as accurate.

r Consumer reporting ageEciesmry not report outdatd negative information. In most cases,a consumer
reporting agencymay not report negative information that is more than sevcn years old, or bankruptcies

TOA 556-1105 Page 7 of 8

 Accessto your file is limited. A consumer reporting agencymay provide information about you only to
people with a valid need-- usually to consider an application with a creditor, insureq employer,landlord, or
other business. The FCRA specifiestlose with a valid need for access.

You must give your consentfor feports to be provided to employers. A consumer reporting agencymay not
give out information about you to your employer, or a potential employeq without your wxitten consent
given to the employer, Written consent generally is not required in the tucking industry. For more
information, go to www.ftc,gov/credit.

You may linit 'lnescreened' offers of credit and insurance you get based oo information in your credit
rePort Unsolcited "prescreened" offers for credit and insurance must include a toll-ftee phone number
you cal call if you choose to rcmove your name and ad&ess from the lists theseoffers are basedon. You
may opt-out with the nationwide credit bureausat 1-888-OPTOUT(1-888-567-8d88).

You may seekdamagesfroE violators. If a consumerreponing agency,og in somecases,a userof consumer

reports or a furnisher of information to a cotrsumerreporting agencyviolates the FCRd you may be able
to sue in state or federal court.

r Identify theft victims arrd active duty ofitary personnelhave additional rights. For more information, visit
www.ftc-gov/credit.

Statesmay enforcethe FCRA, and many stateshave thcir own consumerreporting laws. In somecases,you Eray
have more rights under state law. For more information, contact your stat€ or local consumerproteclion agency
or your state Attomey General, Fedcral enforcers are:

TYPE OF BUSINESS: CONTACT:

Coasuoer rcporting agcocies, crcditore and others oot listed Fcderal Trade Coro.oission: Consumcr Reoporuc Ccnter - FCRA
below. Vashiryton, DC 20580 1-877-3824357
National banlts, fcderal branchesy'agcncies
of forcign banks (word Office of the Comptrollcr of the Currenry
"Natioaal" or initials 'N.A." appesr in or after bank,Enatr'e) Compliancc Manageoeut, Mail Stop 6-6
!0ashingon, DC 20219 800-673-6743
Federal Rescrvc Systcm membcr banks (exc.pr letiolal banks, Fcderal Rcserve Eoard
and fedcal braacheJagencies of forcign benls) Division of ConsuEcr 6c Comnudty A-ffairs
W.shingtor! DC 20551 202452-3693
SaviDgs
associations ard fuerally chaneredsaviugsbalks (wod Office of Thrift Supervision
"Fcderal"or initiale "F.S.B,"appearin ledcralinstitution'strema ConsumerCooplaino
Washington,DC 20552 800-842-6929
Federal credit unions (words 'Fedcral Crcdit Uniol. appcar in National Credit Union Administradon
institution's nemcl 1775 Dukr SEcet
Alcxandria, VA 22314 703-519-4600
State-chancrcd banks thar are not mcrabcrs of rhe Fedcral Fcderal Dcposit lnsurancc Corporation
ReserveSystcm Corrsurn.r RcslroDscCcntcq 2345 Grand Aveoue, Suitc 100
Kansascty,Missouri6410S-2638 7-877-275-3342
Air, surfacc, or rail common carricrs rcgulatcd by formcr Gvil Departrncnt of Transponadon, Office of Financial Managcmcnt
Aeronautics Board or Inrcrstarc Courmcrce Coooission Ve8hington, DC 20590 202-366-1306
Activities subicct to thc Packers aod Stockyald6 Act, 1921 Dcpartment of Agriculture
Officc of Deptty Admin;tator - GIPSA
Vashington DC20250 2O2-7ZO-7OSL

TOA 558-1105 Pagc8 of 8

|,.,'.., D Tr.rsrm.ricr Occidcntal Life Iniurenc. Corlpary Auto-Pay
Erraasamcricalirckrsurancecompanv
E IRANSAMERICA
Eo INSUMNCE & INVESTMENTGROUP
Authorization
C€darR;i&, tA 52499

GAName: Of6ce ID,-

This secrioo euthorizes Tralrsacrerica Occidental Life Insurance Compaay/Tmacamerica life Iosurance Gompany to
deposit your bi-weekly commissionsinto your drecking, money market or savingsaccount- For a checkiug or uoney
market account, pleaseinclude a voidcd check or deposit slip. For a savingsaccoung pleaseindudc a deposit slip.

I herebyauthorizc TransamericaOccidental Life Insurance Company/Iransamerica Life Insurance Company (hereafter

callcd the Company) to initiarc dcposits (crcdits) and./or irnmcdiate/sameday corrections to dcposits, iI proccsscdin
crrog to the fiaaocial institution indicated below. Tbe fioaocial institution is authorized to credit and/or correcr the
a&ounts to my account, This autbority is to remain in full force and effect until the Coupany has rcceived writtcn
notification ftom mc of its teruhation in such timc and such manner as to afford thc Company and Financial lastiti-
tuion a reasonableoppomrniry to act on it.

Note: The CompaDy will not utilize thiE authorization to collcct outstanding balanccsowed to the Company. Alter-
native rep4yneot methods must be established benveen you and the Company in accordancewith the terms of our
contrac,tual agreement

Your NaEe: Your AgeutID:

Social Security Numben

Prderred Addrers:
City St tc Zip Code

Prefcrred Phonc # E-mail Addrcss:

Fbaocial Institution Name:

Fbarcial Institution Address:

Streei City Starc Zp Cade

Che&ing or Savbgs Account Nuober: EFT Traasit/ABA Numbec

Account Types: E Chccking/Money Market E S"viogs

Your Signature
a If thc namc on thc banl eccount is diffcrelt 6om thc cootractcd pcrson
or entiq, a signature &om the accountholdc. or sigoht
ofFccr of dte account (iI a corporarion/frm) is rcquircd.

tt
Accounrboldcr's Signarurc (If signing officer of corporation/firm) Datc

TOA5s&208
rflil]llltrililr||l[l
rDc54r
II€]'LIFE tN!'ESTORS FAX {860}108-7?08
DIRECT DEPOSI'T FORM FOR COII\I ISSIONS tlAlL ('()DE: t'l}]LD COIIPE\SATl()\ (16'r'tloor)

SEC'l'lOl\ | - AGI]"T INFORMA I'lO\

SocialSecurityNunrber ,. _ OR lax lD \umber

Phoue\unlber: { )

.{eent Co||]ract Name

(pbase pnnl)

( ontrLr(! r\ i ls. ! ontll el( Lt.lirnt.ltr' e.t. lt

\1 .( l l o \ l l , D tR t.c f D E P OSII I\t()R u,\ t-l ()\

Selcct services; f] .\utorurtic l)ircct l)cposil [ .tccount ( hrrrrgc

Enterthe accourr( \vherc palnrcntshouldbe disbursed The t)ine-digittransilnunlberand accourlnunrberis encodedatthebotlom r)f
)our check, .-\ cop) ofa l3)l!!8-.lql!!g5 or savirtgsaccounl!\ilhdra\\al sllp !!!Sf bc atlached1oensurethe correct nunrbersarc obtairred.
The accountt)pe indicateswh!'therthe accountis a prinr:lry checkingor p tllary s||vings.

9000

,.\ccountNnrnc 'l ransit \umber \ca()ut|t Nuniber ,\ccount Tr pe Direct Deporit 9;

( \ l u s t b e 1 0 0 9o )

100%

SE( TION tll - ACETiT AtrTlrORIZAl'ION/,IGREEi\I E\T

I . | he ! n d e l s i g n c d ' h e | e b \a u lh o | ilcII.r lI' ill| | l!cskn .s( ) n lt| | ca\ai |i tbl fD cl c(Jtl nni $j xn1Jan

ilt jlh o r i / l r 1 i ( ) l I o \ ' e r i | \ l h e Iir std e p o 5 n ' IvillCn | ,,) ' lin u n C

nl(rla\ oul .l lltc i.lccou l I

I urdcf sland lhal I nlll)-lcnni Lrleth .. .r g { r $ r e l h \ t,\ in ! \r ill Jn r).'l i c.l (' }l crl l l . i n\u}1,,t.l .q,l L.'rl p'.nj .,l ton

''
'//
D atc

PLEASE
Rf,TLRIi CONIPLETED
ORRDVISED
FORiIITO:
\letl-ife lDrcstors,
FicldConrpetrsatiol|
(16'htloor), P.O.Bo\ 9900t?.Hartforrl,CT 06199-0011
(877)MET-0411prompt5 or Fax(860)J08-7708
FieldCornpenslrtion
Form 330.1J(12105)
 MetLifc I ndependentDistribution
Profile Fornr

\ ll. Il\lSA Statement

The N4etlifeal'filiatedinsuranccconrpanies (VlelLifelareconrnrilted ro conductingbusiness rvith the highesterhicaland
legalstandards.\'e havecstablislred atradrtionol integrit)indealin-r$irhourcustonlers\let[-ile hasadopl!'dthe eihical
ma rke tofc onduc t pr ogr ar of t helr s uf anc e\ la r k e t p l a c e S t ! n d a r d s . \ s s o c i a t i o r 1 l l l S , , \ ) . , \ s d e s c r i b e d b e l o \ \ . \ l e l l i fe .a tl
employees and distribrlorsarc c\peclcdb observelhe PrinciplesandCodeot ltlS-{:

l. lo conduclbLtsiness accordingto hish standards ofhoncsl) and lairnessnndlo rcndcrthal scrviccl() our
customelsq hich. irrthe santccircurrstance.rverrould appl\ to or demalldlirr jlsclf.
I -lo provideconipeteut itndiuslt)nter-lbcusedsalcsand s!'1.\'ice.
-l. To engageill activeand laif courperition.
1. -lo proride advertisirrg
and salesmat€rialslhat ire clearas to purposeand lronestand lair as ro conl('nl.
j. To pro\ide lbr fair and erpeditioushandlingofcusrourercorlplai ts and disputes.
6. To maiDlaifla systenrofsupcrvisionand reviervthatis rcasonably desigled1oachieveconrpliance rvith
thesepfinciplcsoferhicalnrarkerconduer.

VllI- Ackno\iledgemcnt:r||dAuthorizaiiotl
Ih.'reb) cerlil-\thnt I h!\c rctd and unJclslarrrl thc itcmsor)lhis appoi|llncnllbrnrandthat nrr ans$ersare lrue and
complele1o(hc bestof rny Inorr lcdge. I hare beenadviscdthat \letlife. lnc.. \lciropolitan.Ceneral,\nrcrican.\lalnul
SlreelSecurilies. \letlife IIvcitors. and Ncu'linglandFinanciilardiheirnftlliatcs(hereafiefreferredtoas "l'he
Conrpal)ies) Ilra\ conduc(iriv.stisatious ir ronncctronwirh nt) fequestto feprese0r 1he ( oIl]pa0icsin dte s0liairirionol
certaininsurance producls.lauthorizeirn inquir)'tr)be nladeofall soufcesdecuredapproprialcb)'The Conlparries for tlre
purposeofobtaininginfornlaliollconcenlirrn nrt trusiness pr'actices andethics.backgrouud. crcdithiston. and financial
status.includin{,but not lillitcd to. nr! rccord.ifan}. on tjle \\itlr the FNR.{ CenlralRecordsDeposilory..\n)
infomrationthat l-he Cofipaniesnr.r)obtairraboLrr me will be treatedascorrfldelltial and may be sharedrvith the appointirrg
gerteralageDl.if nccessan'. I releasethe brokerdealerand (r' its agentsand an) persoDor clttitl , rvhichpror'idcinformation
prrrsuantto lhis arrtho|ization. lionr anl and all liabilnics.claills or la$suitsin an\ nratterfelntedlo e inlb |ation
oblainedfronrany and allofthc abole relirencedsourcesusedlo the exrentpernrittedby law.

I undetstandlhat no right to corlrnrission

or olherconrpensalionshallariseor exist until I ha\e beenappoillledand all due
diligencesucccssiirll)-
approvcd, lf I anr apprlved.I shall acccpras full ron)pensation to bc perlbrnlrdh)
for all ser\,ices
nte.the colnpensalion prorideclin the iipplicableromurissi(rn
nnd ;onrpensationscheduleas issucd.s bstitutcdor chaDge(l
As an appornlcdagen!brokcr.I shirllobser\cltrd be bould bt tlrc rulcsand rcgulillionsof lhe Cornpanies.

I a{reeto conduct \ businessi a.cordanceNith the l\lS.{ PriIciplcsot l:thical\larker ('o,lducr.

CorDorate:

Name lpleasepritri legiblv) Signature Date

\arle (ple as epr ir r lleLr bl\) Sig JtLrrc Da!e

ProlileFonn (3,r:007)
 D/SCLOSURE

By this document.[,4etLifeInc.and all affiliates(hereafterreferredto as "The Companies')discloseto

you that a consumerreportor an rnvestigative consumerrepod containinginformationas to your
character,general reputation,personalcharacteristics and mode of living. may be obtainedfor
employmentpurposesandlor in connectionwith your applicationor request to representThe
Companiesin the solicitation of certainproductsand services.A consumerreportor an investigative
consumerreportmay be securedas paft of a pre- employmentand/orpre-appointment background
investigationand at any time duringyouremployment and/orappointment.Shouldan investigative
consumerreportbe requested.you will havethe rightto demanda completeand accuratedisclosure
of the natureand scopeof the investigation requested.and a writtensummaryof your rightsur]derthe
FairCreditReportingAct

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receiptof a separatedocumentsettingforththe abovedisclosureby MetLifeInc. and

all affiliates(hereafterreferredto as 'The Companies) that a consumerreporl or an investigative
consumerreportmay be obtainedby The Companiesfor employmentpurposesand/orin connection
withyour application or requestto representThe Companiesin the solicitationof certainproductsand
services.A consumerreportor an investigative consumerreportmay be securedas part of its pre-
employmentand/or pre-appointment backgroundinvestigationand at any time during nry
employmentand/or appointment. I authorizethe procurementof such consumerrepofis by The
Companresfor the purposesdisclosedto me. lf I am hired and/or appointed,or if I am already
employedand/orappointed.this authorization will remainon file and will serve as an on-going
authorization The Companaes to procuresuch consumerreportsat any time duringmy employment
and/orapporntment.

I herebyauthorizean inquiryto be madeof all sourcesdeemedappropriate by The Companiesfor the

purposeof obiainingjnformationconcerningmy businesspracticesand ethics,background.credit
history,and financialstatus.including,but not limitedto, my record.if any. on file with the FINRA
CentralRecordsDepository.Any information that The Companiesmay obtainabout me will be
treatedas confidentialand may be sharedwith the employees.agents,or generalagentsof The
Comoanies. if necessarv

Any copyof thisAuthorization

shallhavethe sameauthorityas the original.

tr I would like to receivea copy of atry consunrerreport or investigativeconsumer

reportreceivedby the Conlpanies.

h r r i n gl v l a n a g e isNa ' n e

Pflnled Narne of Applican!rEmpi.yec

!Mtness Sgnature

Prinled Name cf Vvitness

R e f o r mA c l E m p lo ym € n URe g istr a tio n o su r e /Au horzal ton

Dr sc
 D/SCLOSURE

8y thisdocument,MetLifeInc and all affiliates(hereafterreferredto as "The Companies')disclosero

you that a consumerreportor an investigative cor'rsumerreportcontaininginformationas to y our
character.general reputatjon.personalcharacteristics and mode of living, may be obtainedfor
employmentpLrrposgs and/or rn connectionwith your applicatron or requestto representThe
Companiesin the solicitationof certainproductsand services.A consumerreporlor an investigative
consumerreportmay be securedas part of a pre- employmentand/orpre-appotntment background
lnvestagatronand at any time duringyour employmentand/orappointment.Shouldan investigative
consumerreportbe requested,you will havethe rightto demanda cornpleteand accuratedisclosure
of the natureand scopeof the investigation
requested.and a writtensummaryof your rightsunderthe
FairCreditReportingAct.

ACKNOWLEDGMENT AN D AUTHORIZATION

I acknowledgereceiptof a separatedocumentsettingforththe abovedisclosureby lvletLifeInc. and

all affiliates(hereafterreferredto as The Companies) that a consumerreportor an investrgatrve
consumerreportmay be obtainedby The Companiesfor employmentpurposesand/orin connection
with your applicationor requestto representThe Companiesin the solicitationof certainproductsand
servrces.A consumerreport0r an investigative consumerreportnray be securedas part of Its pre-
employment and/or pre-appointmentbackground investigation and at any time during my
employmentand/orappointment.I authorizethe procurement of such consumerreportsby The
Companiesfor the purposesdisclosedto me. lf I am hired and/or appointed.or if I am already
employedand/orappointed,this authorization will remajnon file and will serve as an on-going
authorization The Companiesto procuresuch consumerreportsat any time duringmy employment
and/orappointment

I herebyauthorizean inquiryto be madeof all sourcesdeemedappropriate by The Companiesfor the

purposeof obtaininginformationconcerningmy businesspracticesand ethics,background.credrt
history,and financialstatus includingbut not limitedto my record,if any, on lile with the FINRA
CentralRecordsDepository. Any informationthat The Companiesmay obtain about me will be
treatedas confidentialand may be sharedwith the employees.agents,or generalagents of The
Companies. if necessary.

Any copyof thisAuthorization

shallhav ethe sameauthority
as the original.

H r n n gl M a n a g e isNa m e S i gnarure
of A ppl i cant/E rnpl oyee

mpl oyee
P rnl ed N ameof A ppl i canvE

Print€dName ol Wtness

R e i o r mA c t E mp o yn r e n VRe g r str a lrDosc

n o su r e /Au thori zaton
MLl. this Agtccnrcrrt
shallbc gorcrnedbr thc larrsof th,,.Statcol Delarrarcrrithoutregardto
Delauarechoiccof larrrules.

Sectionl0.l"l. Jurisdicrion.\\ itlt rcspL"ct to an\ acrion.suitor otherproceeding benreen\ll-lC

andBrokcr.cachofthc Particsirrevocablrandunconditionally subnritsto the non-cxclusive
iurisdictionof tlie Lnit,,'dStatesDistrictCourtforrhe Sourlrern DistricrofNe\ \'ork or. if suclr
coun sill not accepr.iurisdict ion. rheSuprcrlcCoun ofthc StateofNes, York or anl,coun ol
competentcivil.!urisdiction sittingin Neu York County.Nel York. \\/ith respccrto an)-acrion.
suitor otherproceedinlbetrveen i\4Ll and Broker.eachol the Partiesirrevocablland
unconditionalllsubrnitsto tlrc non-cxclusivej urisdictiorrol'thL'LlnilcdStatcsDistrictCoun for
theSoLlthern Districtol Dclatiateor. i1'such l ill not ircccpt.iurisdiction.
cr.rult the Superior Court
ofthe Stareof Delauareor an,\,counofconrpetent civil.jurisdictionsittingin Delaware.lnanv
action.suitol otherprocecdint.eaclrol'the Partiesirre\ocabl\andr,rnconditionallr rraircs ancl
agreesnot to asseftby \\a! of motion.asa defenscor olhenvisean; clait'l]sthat it is not subject
to the.iurisdiction ofthc abovecourts.thatsuchactionor suit is broughtin an itrconvenient
tbrunror thatthc \.enucofsuch acrion.suito[ otherproccedingis improper.Eaclrofthe ltanies
herebyagreesthatany tinal andunappca lable.iudgrrentagainsta Partyin connectionwith ant-
action.suitor olherprocectling slrallbc tinal andbindingon suchPartrandthatsucha\ard or
judgenrentmay be entbrcedin any courto,'comperent jurisdiction.eitherwithin or outsideofthe
UnitedStates.A certiliedor cxcmplilicdcopvol sucha*ard or.judgment shallbeconclr.rsivc
evidenceofthe l:rctandar'lloul'tt ofsuch auard or'.judgrrrent.

Section10.15.l{orl \\'c Do Business GLridc.Brokeruckrrowledgcs thathc or shehasreccivccl

Metlit'e's How We Do Business Guide.the ternrsof uhich are incorpomted hercinbl reltrcnce.
andagreesto compll rr ith thc rulesandrequircnrcnrs sct forth in \lctLilt s Hou We Do
Business Guide.

METROPOI,ITANI,IFE
INSURANCI COMPANY
PrintNanreof Broker

aI

-fitle: 'I
itl!':

Address: Date:

NIETLII.E INVISTORS USA

SocialSccuritvNo.: INSLJRANCtT COMPANY
0r 'faxpaler lD No.

Date: Br':

Titlc:

Date:

t4