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:
              Stock Redemption AgreementCross-Purcahse AgreementWait & See Buy-Sell AgreementUnsure, Please Advise
	      
  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? YesNo

  
  If "Yes", please answer the following:

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

  Events Triggering Buyout: DeathDisabilityRetirementBankruptcyOther

  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:
    NoneLowMediumHighVery High 

  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):
    NoYes 

  Additional Comments/Questions: