Membership Application

Fill in the information below to apply for Charleston Estate Planning Council membership.

	Personal Information
First Name:
Last Name:
Company Name:
Email Address:
Website Address:
	Office Information
Address:
City:
State:
Zip Code:
Phone:
Fax:
	Home Information
Address:
City:
State:
Zip Code:
Phone:
Fax:
	Personal History
	I have been a resident of for years.
	I have been actively engaged in Estate Planning for years.
	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
	I have been admitted to practice law in for years.
	I have practiced accounting as a ... Principal Partner Member of the Tax Department of an Accounting Firm ... in for years.
	I have been a Life Underwriter for years. I am an ... Agent Manager General Agent ... of the company. I received my Chartered Life Underwriter designation in the year .
	I am a of the .
	Statement as to estate planning experience and ways in which applicant can contribute to the Council.
	Recommended by (At least 2 people - 1 must be from the same profession as the applicant): 1. 2. 3.
	____________________________________________ (Signature of Applicant if printing) Date: Sunday, September 05, 2010

Please contact mfischer@dixon-hughes.com with questions about council membership.