Fasano Associates Client Application

We are glad that you are interested in using our services.  In order to expedite the process we would like your response to the following questions below.  Upon evaluation and final approval, we will forward to you our standard conditions and consulting agreement via e-mail for execution.  On behalf of the entire team at Fasano Associates, Inc., thank you for your interest and we look forward to your reply.

Organizational information                                    * = required field

Legal Organization Name*:
Organization Type (LLC, Inc, etc.)*:
Street Address*:
Address (cont.):
City*:
State/Province*:
Zip/Postal Code*:
Country:
Phone:
FAX:
Website*:

If your billing address differs from your mailing address, please fill in your billing address below.

Billing Address:
Billing Address (Cont.):
Billing City:
Billing State:
Billing Country:
Billing Zip:
Billing Phone:
Billing FAX:

State of Incorporation of Organization:  

Which of the following characterizes your organization?

Agency
Broker
Provider
Funder/Investor
Other

If you are an agency, which brokers are you dealing with?  

If you are a broker or funder, which providers are you dealing with?  

If other, please explain:  

Are you currently getting life expectancy estimates from other firms?

No
Yes

If yes, which firms?  

What is your currently monthly volume for life expectancy estimates?  

What volume of life expectancy estimates would you expect to order from us per month?  

  Personnel information

Name, title and email address of person authorized to execute agreements on behalf of applicant:

         Full Name:  

         Title:  

         Email Address:  

   Name, title and email address of person designated to receive electronic LE reports:

         Full Name:  

         Title:  

         Email Address:  

   Name, title and email address of accounts receivable contact:

         Full Name:  

         Title:  

         Email Address:  

How did you hear about Fasano Associates?  

      
Note:  if after clicking 'email form' you stay in this form, scroll up to see if there are required fields missing