Membership Application

Upline Code (eg. who introduced you to Harvest Financial)*

First Name*

Last Name*

Nickname (Optional)

Gender*

MaleFemale

Birth Date*

SSN (Number only, no dash, eg. 666889999)*

Mobile Number*

E-mail Address (You will be assign an member code. And you can login with email or member code)*

Password (Minimum length 8)*

Confirm Password (Minimum length 8)*

Home Address*

City*

State*

Zip Code*

I agree to comply with the Compliance Guidelines of Harvest Financial, including but not limited to the following:

I will not solicit sales of insurance policies or securities, directly or indirectly, and I will not supervise agents, unless and until I am fully and properly licensed and appointed.

I will not represent to a customer, or train other agents to represent to a customer, that an index life insurance policy or indexed annuity is a mutual fund.

Upon approval from Harvest Financial, I will obtain copies of the applicable life insurance or annuity replacement procedures and forms, if any, required under the insurance laws of the state(s) in which I have an insurance agent license. I will review them and will comply with them. I will also truthfully and fully complete the information called for on a life insurance or annuity application and agent’s statement regarding replacements.

I will promptly deliver all policies and promptly remit all premiums.

I will not use or provide any policy illustrations except those expressly authorized by the applicable life insurance company, Harvest Financial. I understand that illustrations of a life insurance policy are based on hypothetical rates, and do not represent past or future investment results. I agree I will not use or represent such policy illustrations except as authorized by the life insurance company, Harvest Financial.

I understand that I must complete Harvest Financial and insurance companies required course(s), to include “Anti-Money Laundering”, either prior to obtaining a provider company appointment or within 120 days upon submitting paperwork to a product provider requesting an appointment.

I accept the terms and type my name below as electronic signature*

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