Business Continuation / Buy-Sell Request Form

Please complete the following confidential request form to receive FREE information on Business Continuation / Buy-Sell information. Please note: All fields must be completed. 

  Name:         
  Address:    
  City:         State/Province: 
  Zip Code:   
  Email:      
  Home Phone:   
  Work Phone: 
  

  The type of Buy-Sell Agreement you are interested in learning more about:
              
	      
  Nature of Business or Profession: 
  Years Organized (approx.):        
  Earnings (approx. gross for the last four years):  
  Approximate Book Value (assets minus liabilities): 
  Is there a Buy-Sell agreement in effect now? 

  
  If "Yes", please answer the following:

  Date of Agreement:       
  Type of Agreement:    
  Parties to Agreement: 
  Purchase Price:       
  Funding Mechanism:    

  Events Triggering Buyout: 

  Number of Owners:      			      
  Ages of Owners:       

  Your time frame to establish such a plan is?
     Less than one month    1 to 3 months    3 to 6 months
  Your general awareness on this subject is:
     
  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):
     

  Additional Comments/Questions:

Copyright © 1998 Fielder Financial Management, Ltd.
All Rights Reserved.

Securities are offered through Girard Securities, Inc. member FINRA, SIPC.
Mark R. Fielder, Registered Principal. CA. Insurance Lic. # 0690576.