Pacific Financial Association BMC-85 Application

PACIFIC FINANCIAL ASSOCIATION, INC. ℅ FEDERAL SERVICE CORPORATION

22601 N. 19th Avenue, Suite 202 | Phoenix, Arizona 85027 Telephone: (800) 595-2615 | Fax: (623) 209-2626 | Trust and Claims Administrative Contractor


Company Information


Show exactly as it appears in OP-1 or on Broker's License

Write "Pending" if pending

Write "Pending" if pending

Form of Organization
 Sole Proprietorship Partnership* Corporation* LLC*




Have you or any owner/officer of the company ever been affiliated with any other MC number?

 yes no

If yes, list any Current & Past Broker MC Numbers that any Principals/Officers have ever been affiliated:

Personal Information

Person responsible for signing Trust Agreement:

 Accepted
By checking this electronic signature box, I affirm my identity as the person whose name is affixed as principal; I verify the above statements are true and accurate; and, in the event we have requested Plan #3, I hereby authorize a personal credit inquiry.*

Pacific Financial Contact: