PART 1
Nominee and Nominator Basic Information

BASIC NOMINEE INFORMATION (Complete all fields)

NOMINATOR INFORMATION (Complete all fields)

Relationship to Nominee:

PART 2

Reflections and Impressions on the Nominee's Work with Plans and within the Industry

1. Plan Sponsor Impact. Please provide actual instances (<500 words) of positive impact upon plan sponsors.

2. Plan Participant Impact. Please provide actual instances (<500 words) of positive impact upon plan participant(s).

3. Overall Nomination Considerations. Please provide all information (<1000 words) that you feel should be taken into consideration of this Nominee for this Award.

 PART 3

Nominee-specific Information

Upon completion and submission of this form, nominees will be notified of their nomination and will be required to sign a form stating their agreement to the nomination and their acceptance of the Award Terms & Conditions.

Clearing Broker/Dealer Name (if applicable):

Supervising Principal, if any:

1. Accredited Education:

2. Credentials and Professional Designations (Check all that apply):

3. Continuing Professional Education in the last three years (Please give detail topics):

4. Years serving employer-sponsored retirement plans:

5. Awards and Recognitions (details):

B. EXPERIENCE WITH EMPLOYER-SPONSORED RETIREMENT PLANS

If detailed, accurate information is unavailable, please use approximate numbers and so note.

Plans in total:

Average Plan Retention (yrs):

In past 12 months, New Plans:           Lost Plans:

Target Market: 

With how many product providers do you work?

Participants in total:

C. SERVICE OF EMPLOYER-SPONSORED RETIREMENT PLANS

1. Plan Services (Check all boxes that apply and add detail as appropriate):

2. Plan Sponsor Meetings (Check appropriate box for each):

3. Plan Participant Meetings (Check appropriate box for each):

4. Impact on Retirement Plans in last three years (Please check your experiences and complete as possible, noting average percentages or common details):

5. Compensation (Check boxes and include percentage of total business revenue):

6. Support Staff (Check and number, as appropriate):

D. REFERRALS

Please provide two (2) from different sources (i.e., plan sponsor, plan administrator, plan participant, plan CPA, plan JD, etc.)