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Join Now - New Membership

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CHOOSE PAYMENT OPTION:


		Annual Membership
		$95 One-time Initiation Fee +
		$235 / year


		Monthly Membership
		$95 One-time Initiation Fee +
		$23.50 / month

I hereby authorize the National Ethics Bureau to deduct the $95 one-time initiation fee, plus $235 from my credit card and apply the payment to my annual membership dues.

I hereby authorize the National Ethics Bureau to deduct the $95 one-time initiation fee, plus $23.50 a month from my credit card and apply the payment to my monthly dues.

New York Residents please add $50 for additional state-wide background check.

ENTER PERSONAL INFORMATION: (Confidential)

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First Name:

Middle Initial:

Last Name:

Street Address:

City:

State:

Zip

Daytime Phone:

Fax:

E-mail:

Social Security #:

Date of Birth:

How did you hear about us:

If "Other", describe here:

Sponsor Code: (if applicable)

If Member Referral, name here:

LICENSE VERIFICATION:

Please list ALL LICENSES THAT YOU CURRENTLY HOLD to offer insurance and/or financial services. This includes Resident and Non-Resident Life License(s), Securities License (CRD), Variable Contracts, and Registered Investment Advisor number.

Note: The exact title of your license may vary, depending on state of issue. Please choose which best describes your professional licenses.

License Type	License # State (If Applicable)
Secondary License Type	Secondary License # State (If Applicable)
Additional License Type	Additional License # State (If Applicable)

Note: All members must agree to verification through a seven-year nationwide business-related background check. The results are CONFIDENTIAL.

If you would like to receive a copy of your background check, please check here.

MEMBERSHIP QUESTIONNAIRE
Please read carefully - You must truthfully answer "NO" to qualify for membership.

1)	Within the last seven (7) years, have you had an insurance license, in any state, revoked, restricted, or terminated for cause?	YES	NO
2)	Within the last seven (7) years, have you had a securities license revoked, restricted, or terminated for cause?	YES	NO
3)	Within the last seven (7) years, have you been a defendant or respondent to any consumer complaint or investor-related allegation that resulted in any type of adverse decision, enforcement action, adverse order, or disciplinary sanction or censure against you by any state or federal regulatory agency?	YES	NO
4)	Within the last seven (7) years, have you been subject to any investor-related NASD arbitration or civil proceedings that resulted in any type of award decision to a customer, disgorgement or restitution order, or regulatory fine?	YES	NO
5)	Within the last seven (7) years, have you been the subject of any investigation, inquiry, or complaint by any state or federal regulatory agency, or any broker-dealer, alleging any violations of unethical conduct, prohibited sales practices, or breach of professional standards that resulted in any type of adverse decision, enforcement action, disciplinary sanction, or adverse order, such as a consent order, final order, or cease and desist-type order?	YES	NO
6)	Do you have any regulatory or investor-related complaints that are pending or unsettled, or are you awaiting any arbitration or civil proceedings?	YES	NO
7)	Within the last seven (7) years, have you been convicted of any felony or business-related misdemeanor, or are you currently named as a defendant, respondent, or party to any such criminal or civil action?	YES	NO
8)	Are you currently the subject of any investigation, inquiry, or complaint by any state or federal regulatory agency?	YES	NO
9)	Within the last seven (7) years, have you been censured, fined, reprimanded, or otherwise disciplined by any professional organization or accredited designation?	YES	NO
10)	For new members: Within the last four (4) years, have you been declared bankrupt? For renewing members: Have you filed for bankruptcy or have you been declared bankrupt since your last renewal date?	YES	NO

MEMBERSHIP ACKNOWLEDGMENT
Please read carefully - You must truthfully answer "YES" to qualify for membership.

1)	Have you read the NEB Member Agreement and do you agree to abide by its Terms and Conditions in every respect?	YES	NO
2)	Have you read the NEB Ethics Pledge and do you agree to abide by its principles in every respect?	YES	NO
3)	Do you understand and acknowledge that membership qualifications are subject to change, and that you must re-qualify annually based on the NEB’s most current qualifications?