National Brokerage Associates

Registered representative of and securities offered through: Variable Life Brokerage Distributors (VLBD) a division of ING Financial Partners, Inc.

Member SIPC - Under an Independent Representation Agreement Disclaimer National Brokerage Associates is not a subsidiary of nor controlled by VLBD/ING Financial Partners, Inc.

For Broker Dealer Use Only
Not for Use with the General Public

Copyright © 2002-2005 National Brokerage Associates, Inc. All Rights Reserved. Portions Copyright © 2002-2005 BISG, Inc

	Instructions: Please carefully complete all of the information requested below. All information supplied will be held in the strictest confidence and viewed only by authorized staff members of our agency. Our staff will review your application for access as soon as possible and will notify you by email when your account is ready for use.

*	First Name:
	Middle Initial:
*	Last Name:

*	Agency/Affiliation:

	Date of Birth (mm/dd/yy):
	Social Sec. Number:

	Street Address:
	Apt/Suite #:
	City:
	State:
	Zip:

	Home Phone:
*	Business Phone:
	Fax:
*	E-Mail Address:

	Resident State:
	License Number:
	CRD Number:

	Please specify those lines of business you are actively selling:	Annuities Life LTC Disability Securities Health


*	Desired Username:
*	Password:
*	Re-Type Password:

	Would you like to receive periodic email from us regarding product information and promotions?	Yes No
*	Denotes a Required field