Life School / Life Test Input Sheet

Social Security #: ____________________

Last name: ____________________

First name: ____________________

Full Middle name: ____________________

Date of Birth: _____ / _____ / _______

Gender? Male or Female

E-mail Address: ____________________

US Citizen? Yes or No

Are you affiliated with a financial institution or bank? Answer: No

Home Address: ____________________________________________________________

Street Suite/Apt # City State Zip Code

Phone #: _____ - ______ - ________

Do you have a disability/impairment for which you may need assistance? Yes or No

Work History (Past 5 years):

From: ______ Employer: ______________ Position: ___________
To: ______ City/State: ____________ / ____

From: ______ Employer: ______________ Position: ___________

To: ______ City/State: ____________ / ____

From: ______ Employer: ______________ Position: ___________

To: ______ City/State: ____________ / ____

From: ______ Employer: ______________ Position: ___________

To: ______ City/State: ____________ / ____

Do you have an insurance license or ever held one? Yes or No

If Yes: Is License Active? Yes or No
Prelicensing completed when? ____/_______ (mm/yyyy)

Any Felonies or Misdemeanors ever? Yes or No

If Yes describe: ____________________

Credit Card: Visa / MasterCard

#: _________________________ Exp: ___/____ 3 Digit Code on Back: _______

Test Date(s): Month / Day / Time: _________ / _____ / ________

Month / Day / Time: _________ / _____ / ________
Month / Day / Time: _________ / _____ / ________