Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

BOLD ITEMS REQUIRED TO SUBMIT FORM.

What is the current estimated value of your home?
What is the estimated balance of your current mortgage?
What is your monthly payment?
This is your:	Primary Residence -SELECT ONE- Second Home Investment Property
What is your Age:	-SELECT ONE- Under 30 30-45 45-61 62+
Where did you hear about us?	-Select One- AFA Radio AFA Journal Promise Keepers Other Ministry Referral Other
Are you a registered representative interested in becoming a member of FFP?	YES NO
Are there other items you would like to learn more about?	Investing with Values (eliminate abortion, pornography, same-sex lifestyle, gambling, tobacco and alcohol from my portfolio) Retirement plan, IRA, 401(k) rollover Developing a financial plan Family protection and insurance Estate management, trusts and wills Incorporating a Financial Stewardship Plan to my daily life: debit card, credit card and money market account (ability to choose one, two or all three) Family Alert Notification System in the case of an emergency Credit Card Processing for businesses

Additional Comments: