FFM - Roth Request Form

ROTH IRA General Request Form

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

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

  Occupation: 
  Employer:   
  
  Are you looking to possibly establish a new Roth IRA plan?

     Yes   No

  Do you own an IRA now?          
     Yes   No
  
  Are you looking to transfer your IRA plan to a Roth 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) a Roth 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:

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