THE WORRYFREE RETIREMENT® NETWORK

MEMBER APPLICATION

* Asterisk Indicates Required Field

Date *

Month Day Year

Agency Name

Dressander|BHC (DBHC) Marketing Consultant Name

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Mobile Phone

Business Phone *

Business eMail *

Current FMO *

FIA Annuity Premiums Current Year *

Enter Dollar Amount

FIA Annuity Premiums Previous Year *

Enter Dollar Amount

Primary Carriers with whom the above FIA production was placed *

Approx Dollars Spent on Marketing Current Year *

Enter Dollar Amount

Approx Dollars Spent on Marketing Previous Year *

Enter Dollar Amount

1. Will you commit to a one-time set-up fee of $450 and a recurring monthly subscription fee of $199 for access to website and income planning software/database? *

Yes No

2. Will you commit both financially and mentally to the success of the program by producing a minimum of $2 million in annual indexed annuity production in the next 12 months? *

Yes No

3. Will you commit to placing all of your indexed annuity business solely with DBHC? *

Yes No

4. Assuming you do not already have your American Equity contract with DBHC, will you commit to immediately moving it to DBHC? *

Yes No

5. Will you commit to immediately moving at least two of the core carriers listed to DBHC: National Western, Allianz, F&G, Nationwide, Forethought and/or Annexus? *

Yes No

6. If not already an RIA (registered investment advisor), will you commit to obtaining your RIA (series 65 license) within one year after joining the Network? *

Yes No

7. Will you agree that you currently have $25,000 of capital/savings (for marketing and branding efforts) OR can confirm that you already have a fairly large group of prospects you can contact about the WorryFree Retirement? *

Yes No

8. Will you commit 100% of your time and energy to the 6-session coaching calls with Tony and complete all homework prior to each session? *

Yes No

9. If you desire to be released from the Network, will you agree to return all materials to DBHC and WorryFree, Inc.? *

Yes No

Signature *

I understand I will be asked to complete a Kolbe A™ Index assessment as part of the WorryFree Retirement^® Network application process and will be personally responsible for the associated cost. Applicant will forward results of Kolbe A™ Index to both DBHC and WorryFree, Inc. Completion of the assessment does not guarantee acceptance into membership.

A Marketing Consultant from Dressander|BHC will contact you to discuss next steps in detail.