PFA BMC-85 Application

PACIFIC FINANCIAL ASSOCIATION, INC. ℅ FEDERAL SERVICE CORPORATION

22601 N. 19th Avenue, Suite 202 | Phoenix, Arizona 85027 Telephone: (800) 595-2615 | Fax: (623) 209-2626 | Trust and Claims Administrative Contractor

    Company Information

    Show exactly as it appears in OP-1 or on Broker's License

    Write "Pending" if pending

    Write "Pending" if pending

    Form of Organization

    Sole ProprietorshipPartnership*Corporation*LLC*

    Have you or any owner/officer of the company ever been affiliated with any other MC number?

    yesno

    If yes, list any Current & Past Broker MC Numbers that any Principals/Officers have ever been affiliated:

    Personal Information

    Person responsible for signing Trust Agreement:

    Accepted

    By checking this electronic signature box, I affirm my identity as the person whose name is affixed as principal; I verify the above statements are true and accurate; and, in the event we have requested Plan #3, I hereby authorize a personal credit inquiry.*

    Pacific Financial Contact: