Business Continuation / Buy-Sell Request Form

Please complete the following confidential request form to receive FREE information on Business Continuation / Buy-Sell information. Please note: All fields must be completed.

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

  The type of Buy-Sell Agreement you are interested in learning more about:
              
	      
  Nature of Business or Profession: 
  Years Organized (approx.):        
  Earnings (approx. gross for the last four years):  
  Approximate Book Value (assets minus liabilities): 
  Is there a Buy-Sell agreement in effect now? 

  
  If "Yes", please answer the following:

  Date of Agreement:       
  Type of Agreement:    
  Parties to Agreement: 
  Purchase Price:       
  Funding Mechanism:    

  Events Triggering Buyout: 

  Number of Owners:      			      
  Ages of Owners:       

  Your time frame to establish such a 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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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.