Rollover/Transfer General Request Form

Please complete the following confidential request form to receive FREE information on Rollover and Transfer options. Please note: All fields must be completed. 

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

  What type of plan are you looking to rollover or transfer?
    

  Will you be making ongoing contributions?
     Yes   No
  
  I consider myself a:
     Aggressive Investor    Moderate Investor   
     Conservative           Willing to accept NO risk  
    
  Are you a mutual fund investor?
     Yes   No
    
  Your age is:
     25-35    35-45    45-55    55-65   65-Above
    
  Your tax bracket is:
     28%    31%    36%    39.6%    Unknown
  
  Approximate rollover/transfer amount: 
  
  Your estimated 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.