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QUALIFICATION FORM

Incomplete forms will not be processed. A complimentary subscription to Benefits Selling will be sent to those applicants who qualify. The publisher reserves the right to limit the number of subscriptions accepted.

1.	I wish to receive Benefits Selling magazine FREE of charge.

Yes!

No

NOTE: In order to be considered for a subscription to Benefits Selling, you MUST select Yes above. If you do not select Yes, you will not receive a complimentary subscription to Benefits Selling.

2.	I recommend, specify or sell: group and/or voluntary benefits, retirement plans, or consumer-driven healthcare products.

Yes

No

3.	The following best describes my Title:

4.	The markets my firm currently/plans to target include: (check all that apply)

Small Business Market

Large Business Market

Association Market

Government Market

Bank Market

Other (specify)

5.	My firm works with groups of the following sizes: (check all that apply)

100 lives and under

101 to 1,000 lives

1,001 to 5,000 lives

5,001 or more lives

6.	My Income is:

7.	I have been involved in selling for...

8.	I am

9.	We require a unique identifying piece of information in order to verify this request is valid. What month were you born?

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