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IRA General Request Form

Please complete the following request form to receive FREE information on IRA investing. Please note: All fields must be completed.

  City:         State/Province: 
  Zip Code:   
  Home Phone:   
  Work Phone: 

  Do you own an IRA now?          
     Yes   No
  Are you looking for a possible "rollover" or transfer of your IRA plan?   
     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
  Your estimated time frame to purchase (or rollover) an IRA 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:


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Copyright 1998 Fielder Financial Management, LTD.
All Rights Reserved.

Securities offered through Fortune Financial Services, Inc. member FINRA, SIPC.  Fielder Financial Management, Ltd. not affiliated with Fortune Financial Services, Inc.  Mark Fielder, Financial Professional, CA. Insurance Lic. # 0690576.