Name  
2. Firm or Affiliation  
3. Office Mailing Address   
     Web Site
4. Bus Ph 5. Fax    6. E-Mail  
7. Membership Category (Please complete the relevant section)
    (a) Attorney: I have been admitted to practice law in   for years.
          I am member in good  standing of the  Bar Association(s).
    (b) CPA's & Accountants:      I have practiced accounting as a Principal    Partner    Member  of the tax department
          of an accounting firm in (city) (state) for year(s).
          I am a member in good standing of the   CT Society of CPA's         CT Society of Enrolled Agents
          National Society of Public Accountants or  (other) . 
                                       I   (am  am not)  a CPA.                I   (am  am not)  an Enrolled Agent.
    (c) Life Insurance Underwriters:                  I have been a Life Insurance Underwriter for years and
          am an Agent    Manager     General Agent of the Company.
           I am a member in good standing of the Life Underwriters Association.
           I received  my Chartered Life Underwriter designation in (year).
           I am a member of the American Society of CLU & ChFc Chapter.
    (d) Trust Officers: I am (title) of the (Bank or Trust Co.)
          and have been an officer of the bank since (year).
    (e) Probate Judge:    I have been the probate judge for the District of  since (year).
    (f) Financial Planner:    I am a  Registered Investment Advisor   Registered Investment Advisor Agent
           with the following     SEC     CT     RI      Other (specify) . 
                         I hold the CFP designation: ( Yes No )               I hold the ChFP designation ( Yes No )
                         I am a member of the Financial Planning Association ( Yes No )
    (g) Other: Please describe estate and tax planning experience as Investment advisor, financial planner,
          tax consultant, IRS auditor or practitioner of related occupation (below or on a separate sheet).

                 ____________________                ___________________________________________________________
                       Date                                                             Signature of Applicant

Please print out and send (include check for membership fee of $125) to:
Estate and Tax Planning Council of Eastern Connecticut, Inc.,  P.O. Box 152,  Mystic, CT 06355 
For more information email us at  mail@etpcec.org