SMRM Request - Annuity Agents Alliance

Safe Money Radio Marketing Airtime Request

Full name of host #1: *

First

Last

Cell phone number: *

Office direct number:

Email: *

Full name of host #2 (If applicable):

First

Last

Cell phone number:

Office direct number:

Email:

Full name of principle #1 (If different from host):

First

Last

Cell phone number:

Office direct number:

Email:

Full name of principle #2 (If applicable):

First

Last

Cell phone number:

Office direct number:

Email:

General office phone number:

Billing address: *

Address Line 1

Address Line 2

City

State

Zip Code

FMO name: *

Recruiter name: *

First

Last

Recruiter email: *

Recruiter direct phone number: *

Securities licensed? *

FIA production (Last 12 months): *

Monthly SMRM marketing budget: *

Miles you're willing to drive for appointments: *

Are you ready to buy airtime? *

Have contracts been signed by all hosts and principles? *

Who is paying for the airtime (If other than host)?

What cities or area does the host want to air from? *

Any special requests from the host? *

Any other information? *

Safe Money Radio Marketing Airtime Request

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