1.	Name:	_______________________________
Office Address:		_______________________________	Telephone:	_________________
Home Address:		_______________________________	Telephone:	_________________

2.	I have been a resident of ________________________ for ________ years.
3.	I have been actively engaged in Estate Planning for _____________ years.
4.	I am a member in good standing of the:

________________	Bar Association
________________	Institute of Accountants and am a Certified Public Accountant
________________	Life Underwriters Association (Chapter of Chartered Life Underwriters)

5.	a)	I have been admitted to practice law in ____________________ for  _________ years.
	b)	I have practiced accounting as a _____(Principal) _____(Partner) _____(Member of the Tax Department of an Accounting firm) in _______________________ for _______ years.
	c)	I have been a Life Underwriter for ______ years. I am an ________(Agent) _______(Manager) ______ (General Agent) of  the __________________________________________ Company.
	d)	I am a _______________________ of the __________________________________.

( Title)

( Bank or Trust Company)

6.	Statement as to estate planning experience and ways in which applicant can contribute to the Council. (You may use back of form or attach statement.)

	__________________________________
	(Signature of Applicant)
	___________________________________Date
Recommended by:
1. __________________________________
2. __________________________________
(One of the recommending members must be of the same profession as the applicant)