Test New Application This page is to test the new form to contact application. It needs to go to a payment page. I’m working on that. Membership Application: Please type your name as you would like it to appear on your diploma. First Name* ? Enter your name as you would like it to appear on your FEPS certification diploma. Last Name* Middle Name Nick Name/Preferred First Name ? Enter the first name you prefer if not the same as that entered in first name. Date of Birth* Suffix -None-Jr.Sr.PhDIIIII Professional Designation -None-AAIAISARMCFPCLUCRMCSACTFA Your Company Name Cell Phone* Preferred Email* Secondary Email ? Please enter an email we can use if your primary email is disabled or not working. Website URL National Producer Number* Resident License Number* Resident License State* -None-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Upline Agency Referred By ? Please enter a note to tell us how you found us. Office Address 1* Office Address 2 Office City* Office State* -None-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Office Zip* Home Address 1* Home Address 2 Home City* Home State* -None-Option 1Option 2AlabamaAlaskaArizonaAransasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Home Zip*