Target Insurance Services, Inc.

	Instructions: Please answer all of the questions below. Target Insurance will keep this information strictly confidential and will review your application as soon as possible. You will be notified via e-mail when your account is ready for use. PLEASE NOTE: If you have a problem submitting this form, it is likely that you are using Internet Explorer version 6 or later. You will have to make a quick modification to your browser in order to submit the form. Please use your back button now to go back to the Home page. Click on any button on the left side of the page. This will bring up a Login Page. Click on the verbiage just to the right of the User ID box and follow those instructions.

*	First Name:
	Middle Initial:
*	Last Name:

*	Agency/Affiliation:

	Date of Birth (mm/dd/yy):
	Social Sec. Number:

	Street Address:
	Apt/Suite #:
	City:
	State:
	Zip:

	Home Phone:
*	Business Phone:
	Fax:
*	E-Mail Address:

	Resident State:
	License Number:
	CRD Number:

	Please specify those lines of business you are actively selling:	Annuities Life LTC Disability Securities Health


*	Desired Username:
*	Password:
*	Re-Type Password:

	Would you like to receive periodic email from us regarding product information and promotions?	Yes No
*	Denotes a Required field

Registered representative of and securities offered through: Variable Life Brokerage Distributors (VLBD) a division
of ING Financial Partners, Inc. Member SIPC | Target Insurance Services is not a subsidiary of nor controlled by VLBD/ING Financial Partners, Inc.
Copyright © 2002-2005 Target Insurance Services All Rights Reserved. Portions Copyright © 2002-2005 BISG, Inc | Disclaimer