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Financial Advisor Boot Camp : Application

Million Dollar Producer's 2-Day Financial Advisor Boot Camp

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First Name

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Last Name

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Company Name

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Address

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City

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State

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Postal/Zip Code

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Business Phone

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Fax

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Home Phone (Emergency Only)

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E-mail Address

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Birth date (mm/dd/yy)

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Broker-Dealer

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Years of Experience

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How did you hear about our sessions?

Current Annual Production Level (Please Check One):

__ $100,000 - $250,000 __ $500,000 - $750,000 __ $1,000,000 or more
__ $250,000 - $500,000 __ $750,000 - $1,000,000

üYes! Please register me for:

______2-Day Boot Camp $1,999 (member) $2,300 (non-member)*
*includes 12 months of membership to the www.MDPRODUCER.com website

Million Dollar Producer's sessions are designed to help each participant achieve extraordinary goals. This program will help provide a structure that can elevate your production and help you operate more efficiently. Any reproduction, presentation, or commercial use of the concepts, strategies, methods, materials, and all the other trademarks, copyrights, and intellectual property of Million Dollar Producer, Inc., is prohibited without specific written permission from Million Dollar Producer, Inc.

"I hereby apply for acceptance into Million Dollar Producer's training sessions. In doing so, I commit myself to full participation in the program. I acknowledge that all of my decisions and actions and the consequence of such decisions and actions, whether made in the context of this program or not, are entirely my own responsibility. I enclose the non-refundable registration fee. I am aware that my registration fee is non-refundable. I understand that it is my responsibility to handle my own travel and travel-related expenses and that the sessions are set and have no make-up date. In the event of an emergency, Million Dollar Producer reserves the right to re-schedule and/or substitute the session."

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Signature Date

For credit card payments only:

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Name on Card Number

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Credit Card Number

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Expiration Date

I ______________________________________________ hereby authorize Million Dollar Producer, Inc., to charge
the credit card account number above in the amount of $__________________________________________

Cardholder Signature:_________________________________________________________________________