If you would like to learn more about our representative programs, fill out the information request form below.
Name of the Business:
Is the Business Investment Related? Yes No Please select Yes or No
Address of the Business:
Nature of the Business:
Your Position, Title or Relationship with the Business:
Start Date of your Relationship with the Business:
Approximate Hours/Month that you Devote to the Business:
Approximate Hours that you Devote to the Business during Securities Trading Hours:
Briefly Describe Your Duties:
Name: (First, Middle, Last)
Address:
City:
State: Select a state -------------------- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Distric of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Northern Mariana Islands Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (AE) Armed Forces Americas Armed Forces Pacific
Zip:
Work Phone:
Home Phone:
E-Mail Address:
Social Security #:
Date of Birth: Month -------- January February March April May June July August September October November December Day --- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year ---- 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921
CRD#:
Fax:
Business Address
Same as personal address
Emergency Contact 1:
Name: Phone:
Emergency Contact 2:
Current or Last Broker Dealer/Place of Business:
Name:
Phone:
Website Address: Please list all websites
Social Media Sites: Please list all websites
Is your current office an OSJ(Office of Supervisory Jurisdiction)? Please select Yes or No Yes No
Is your branch located in apersonal residence? Please select Yes or No Yes No
Employment Status: Currently Employed My Term Date was:
Licenses Held: Please check at least one license type
Series 6 Series 7 Series 63 Series 66 Series 24 Series 27
Others:
Industry Designations: Please check at least one designation
LUTCF CLU ChFC CEP CFS CMFC CPA None
Insurance Licenses Held: Please select at least one
Life Health P&C
Have you completed Firm Element this year? Please select Yes or No
Yes No
If yes, please include certificate of completion.
List states in which you are currently registered for securities transactions:
List states in which you are currently insurance licensed:
List any other states in which you would like to be licensed:
Most Recent Payout %
*Please attach most recent commission statement or 1099's for the current year: and year end statements for the prior two years:
List as Percentage:
Stocks % Bonds % Mutual Funds % Variable Products %
List Mutual Fund and Variable Companies that you prefer to do business with:
Are you currently involved in the offer of, or otherwise participating in, any type of private placement? Please select Yes or No
If yes, please identify the private placement and describe your involvement.
Number of written complaints in the past 24 months
Number of verbal complaints in the past 24 months
Do you have any disclosure events ("Yes" answers) on your form U-4? Please select Yes or No Yes No
If yes, please list the details, including dates, allegations, and dollar amounts of claims, of any situation that has or will result in a "Yes" answer on your U-4.
Are there any special supervisory procedures required for you? Yes No Please select Yes or No
If yes, please explain
Are you a Registered Investment Advisor? Please select Yes or No
If yes, please enclose a copy of your ADV:
If yes, are you registered with: SEC State
Date Registered: / /
Number of Clients:
Total Assets Under Management: $
* Note: If you are a Registered Investment Advisor, you will be required to furnish copies of all your books and records concerning RIA activity to the Broker Dealer.
Are you currently engaged in any other business either as a proprieter, partner, officer, director, employee, trustee, agent, or otherwise? (Please exclude non investment-related activity that is exclusively charitable, civic, religious, or fraternal and is recognized as tax exempt.) Yes No Please select Yes or No
As a general rule, if you receive compensation for an activity, then it is recognized as "Other Business." You DO NOT need to list your employment with MFSI.
If yes, please provide the following details for each outside business:
Do you have any restrictions on your activities from your current BD? Yes No Please select Yes or No
If yes, please attach a copy of the Agreement:
Approximate number of customers: (number of persons)
Approximate number of account registrations: (ex. Individual, IRA, Joint Accounts)
Approximate number of Brokerage Accounts:
Approximate number of Non-Brokerage Accounts:
What date do you expect to register with MFSI?
Do you have an assistant or other clerical support that assists you with client information? Please select Yes or No Yes No
If yes, please list the names and phone numbers for all your assistants below:
I hereby authorize MidAmerica Financial Services, Inc., or its authorized agents, to investigate and verify any of the information referenced on this Pre-Hire and Disclosure Form, and to search for and obtain copies of recorded information concerning me. These include but are not limited to the following: employment history, securities registration history, NYSE records, FINRA CRD records, criminal records (felony and misdemeanor), bankruptcy records, consumer credit reports and educational background. MidAmerica will maintain the confidentiality of any information obtained under this authorization, and will use such information only as necessary to evaluate the application; however, I understand that MidAmerica has an obligation to report to the FINRA in the event MidAmerica becomes aware that there is false, misleading or incomplete information on my U-4.
I understand that, upon my separate written request, I will be advised if a Consumer Credit Report was requested and given the name, address and phone number and scope of the request, if applicable. I understand that I have the right to obtain a copy of such Credit Report.
If I signed a prior representative agreement that contains a covenant against competition and MidAmerica grants my application for association, I understand that I will be solely responsible for any violation or breach of such agreement that may arise out of my activities while associated with MidAmerica and I hereby agree to indemnify and hold MidAmerica harmless from any liability thereunder.
I understand that my application for association can only be approved by the registered principals of MidAmerica. I understand that all fees paid to MidAmerica are non-refundable. I hereby release MidAmerica from any liability arising out of the application process:
Please forward all requested documents to:
MidAmerica Financial Services, Inc. 2230 E. 32nd Street, Suite B Joplin, MO 64804 Attn: Jeff Stinnett Phone: 888-526-2001 Fax: 417-623-9557
How did you hear about us?
Enter your name below in lieu of your signature:
Registered Representative
