Form La02298 - Partnering With Lincoln Financial (Page 3 of 4) in pdf

PROFESSIONAL PROFILE - ANNUITY REPRESENTATIVE

A. Personal Information

Male

Female

Full Name: __________________________________________________________________________ Nickname: _________________________________

Date of Birth: _____________________________________________ Social Security Number: ______________________________________________

Business Street: _________________________________ City: _______________________ State: _____ Zip: _________________ County: _______________

Business Phone: __________________________ Fax: ___________________________ Email address: __________________________________________

Home Street: _______________________________ City: _______________________ State: _____ Zip: _________________ County: _______________

Home Ph: ___________________ Prof Desig:

CLU

ChFC

CFP

CFC

RFP

MSFS

LUTCF

Other _________________

May we publish your name in Company publications?

Yes

No If no, is recognition (awards, conference) acceptable?

Yes

Federal and state laws prohibit discrimination in contracting because of race, color, religion, age sex, national orgin, or disability.

Broker Dealer Name: ____________________________________________________________________

Tax ID: ______________________

Financial Institution Name: _______________________________________________________________

Tax ID: ______________________

C. Licenses Held

List states in which you wish to be appointed._____________________________________________________________________________________

NASD License

Yes

CRD # ___________________________________________

D. Please read and answer each

question. (Attach a written explanation, including date of the event and date of discharge, for any yes

answers. If anything occurs, which results in a change to any of your answers, you must notify Lincoln, in writing, within 30 days of the

occurrence.

Yes

Are you now or have you ever been the subject of any complaint, investigation, or proceeding by any

Insurance Department, the SEC, or any federal or state regulatory agency?

Have you ever been convicted of or pleaded guilty or nolo contendere to a felony or misdemeanor other

than a traffic offense?

Are you currently, or have you ever been involved in a bankruptcy (personal or any business in which you

had control or an ownership interest), pending litigations in which you are a defendant, had a salary

garnished or had liens or judgments against you?

Are you currently, or have you ever been the subject of any customer complaint or complaint or proceeding

by any securities, insurance or commodities regulatory body or organization?

Have you ever had your contract, appointment or employment arrangement terminated or have you been

permitted to resign from any insurance company or other financial services employer for any reason other

than low production?

Are you currently, or have you ever been refused a license to sell insurance or been refused membership in

any securities regulatory body or organization or had a license suspended or revoked by any securities and/or

State Insurance Department?

Are currently a party or in the past ten years, have you been a party to any lawsuit, arbitration or civil litigation?

By signing below, I certify that the foregoing answers are true and correct to the best of my knowledge and belief. I also give The Lincoln

National Life Insurance Company and its affiliates permission to investigate as necessary to verify this information and to share the

information with parties recruiting and recommending my appointment unless I direct you otherwise. This authorization, in original or copy

form, is valid now or any time in the future.

______________________________________________________________

______________________________

Signature of Applicant

Date

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.

Page 1 of 1

LA02296VA

11/07

Form La02298 - Partnering With Lincoln Financial Page 3

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