Wells Family of Companies | Candidate Information Form

General Information Name:
(Please include First Name, Middle Name and Last Name)
Nick Name:
Telephone Number:
Company / DBA Name:
Are you affiliated with any other producers?
If "Yes", please provide name(s) of other person(s):
Do you have a website? Do you have a website? If "Yes", please provide URL:

Licensing Information Current Securities Licenses Held: Current Securities Licenses Held: 6   7 24   26   63 65   66
Other:
If not currently registered with a broker/dealer, when will your license(s) expire?
Professional Designations: CPA CFP ChFC   CLU   CFA   CFS   CIC EA
Other:

Personal Production What is your gross securities commission total (not including fixed insurance)?
                                                                                  Current: Previous Year:
What was your fixed insurance commission total?            Current:   Previous Year:
What are your total assets under management (AUM)?    Current:   Previous Year:
What were your fee revenues from AUM?                      Current:   Previous Year:

Professional Affiliations Your current Broker/Dealer:
Your current Registered Investment Advisor:
If you are affiliated with an insurance marketing organization, please list:
What two things about your current broker-dealer prompt you to seek a change?
1.)
2.)

Click the Submit button to automatically email your Candidate Information Form

If you prefer to fax - 863-294-6657, ATTN: CONFIDENTIAL TO CLINTON WILLIAMS

Valor Financial Securities, LLC. Member FINRA & SIPC