2014 MEMBERSHIP APPLICATION
Select One:
□ New Application
□ Renewal Application
Select One:
□ Member
□ Associate Member
CONTACT INFORMATION
First Name
Last Name
Company Name
Email Address *
Business Address
Mailing Address (if different from
business)
Telephone/Alternate Telephone
Fax
Website Address
Last Four Digits of Social Security #
CFP Membership #
*Most communications will be by email
Membership dues are $225/year, renewals as per day of original application approval. Please pay by check or
credit card. Make check payable to “Association of Divorce Financial Planners” or “ADFP.” Mail check and
application to: Pam Humbert, Administrative Assistant, Association of Divorce Financial Planners, 514 Fourth
Street, East Northport, NY 11731 Phone: 888-838-7773 & Fax: 631-754-6125;
Email: ADFP@DivorceAndFinance.org
PLEASE ANSWER ALL STATEMENTS BELOW (YES, NO or N/A).
1. I have a professional interest in divorce financial planning □ Yes □ No □ N/A
2. I have read the ADFP Member Handbook (posted on www.DivorceAndFinance.org) and am familiar
with its contents. □ Yes □ No □ N/A
3. I have read and am supportive of the ADFP Mission Statement. □ Yes □ No □ N/A
Association of Divorce Financial Planners Application 2014
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4. I am in full compliance with the membership criteria for the class of membership for which I am
applying. □ Yes □ No □ N/A
5. If a divorce financial planning practitioner, I agree to abide by the Practice and Professional Standards
established by ADFP. □ Yes □ No □ N/A
6. I charge a reasonable and customary monetary fee-for-service for divorce financial planning and do not
engage in rebating or alternative fee arrangements including offering divorce financial planning as a
free service in exchange for or in anticipation of acquiring or being otherwise linked to a post-divorce
money or investment management engagement or product sale, directly or indirectly through other
professional relationships. □ Yes □ No □ N/A
7. I have an engagement letter that clearly delineates the scope of divorce financial planning duties I will
perform and includes my fee schedule. □ Yes □ No □ N/A
8. I have errors and omissions insurance that covers divorce financial planning. □ Yes □ No □ N/A
9. If a registered representative with a broker/dealer, I can present a letter from my broker/dealer stating
approval for the outside business activity of providing services to and charging fees for divorce
financial planning advice to individuals. □ Yes □ No □ N/A
10. I agree to supply proof of any and all of the above documentation if requested by the ADFP.
□ Yes □ No □ N/A
11. I agree to notify the ADFP Board within two (2) weeks of any situation or event that could negatively
impact my membership status. □ Yes □ No □ N/A
12. Have you or any business in which you are/were an owner, partner, officer, director or manager been
found liable in any lawsuit or arbitration proceeding involving allegations of fraud, misappropriation or
conversion of funds (skip if previously disclosed)? □ Yes □ No □ N/A
13. Have you or any business in which you are/were an owner, partner, officer, director or manager been
convicted of or pled guilty or no contest in any court to a crime, had a judgment withheld or deferred,
or are you currently charged with committing a crime (skip if previously disclosed)?
□ Yes □ No □ N/A
14. I agree to attend four (4) hours of ADFP chapter meetings per year if is a local chapter within a 50-mile
radius of my home or office. □ Yes □ No □ N/A
15. I wish to associate with the following chapter: _________________________________________
16. Please provide further details for any “No” answers to Questions 1-11 above. If you have any
deficiencies, for example you are short on continuing education credits, provide an explanation for how
you plan to make these up. Use additional pages if necessary.
___________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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___________________________________________________________________________________
___________________________________________________________________________________
BACKGROUND INFORMATION
Primary Profession: _________________________________
DESIGNATIONS
Specific to Divorce Financial Planning
□ CDFA ™
□ FDS
□ CFDS ™
□ Other Divorce-Related
Year: _____
Year: _____
Year: _____
Designations or Degrees
_____________________
_____________________
Year: _____
Year: _____
Financial Designations or Degrees
□ CFP®
Year: _____
□ ChFC ®
□ CPA
□ CPA/PFS
□ CA (Chartered Accountant)
□ CGA (Certified General Accountant)
□ Registered Investment Advisor
Year: _____
Year: _____
Year: _____
Year: _____
Year: _____
SEC ______ State ________
Year: _____
□ Investment Adviser Representative
IAR: ______________
Year: _____
□ FINRA Registered Representative
Broker Dealer: ________________ Year: _____
□ Other Financial Designations & years as above (please include monitoring organization name with
designation)
____________________________________________________________________________________
____________________________________________________________________________________
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Tax Designations or Degrees
□ EA
□ MS in Taxation
□ LLM in Taxation
Other Designations or Degrees
□ JD
Year: _____
Year: _____
Year: _____
Year: _____
□ PhD _____________
□ LCSW
□ LPC
□ MFT
□ MA______________
□ Other Designations
Year: _____
_________________
_________________
Year: _____
Year: _____
Year: _____
Year: _____
Year: _____
Year: _____
EXPERIENCE
Experience in financial planning (years)
□<3
□3-5
□ 5 - 10
□ > 10
Number of comprehensive divorce financial planning engagements:
□<5
□ 5 -10
□ 10-25
□ > 25
CONTINUING EDUCATION
Total divorce-related continuing education credits _______
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2013 Divorce-Related Courses
Date
Course/Subject
Provider
# of
Credits
Type (CFP, CPE, CLE)
ADFP Ethics
Date
Location
# of Credits
ADFP Chapter Meetings
Date
Course/Subject
Association of Divorce Financial Planners Application 2014
# of Credits
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ADFP ACTIVITIES
I agree to be actively involved in the ADFP.
□ Yes
□ No
I wish to associate with the following Chapter:
□ Atlanta
□ Michigan
□ California
□ Northern Greater New York Metro
□ Connecticut
□ Northern New England
□ Florida
□ Ohio
□ Greater Boston Area
□ Southern New England
□ Greater New York Metro
□ Tennessee
□ Greater Philadelphia
□ Pacific Northwest
□ Illinois (DivorceIllinois)
□ Long Island (NY)
□ NEW local Chapter proposed _______________________
The ADFP is an all volunteer organization. Please indicate ways you would like to help:
________ Annual Conference
________ Marketing, Publicity and Public Relations
________ Membership Recruitment and Development
________ Administration
________ Newsletter
________ Education
________ Chapter Development
________ Development of Practice and Professional Standards
________ Website Liaison and Maintenance
________ Development of Mentorship and Educational Programs
________ Sponsor/Exhibitor
________ Other (please specify ______________________________________________
Association of Divorce Financial Planners Application 2014
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Submission of this application signifies that the information contained herein is, to the best of my knowledge,
true, accurate, and complete.
DISCLAIMER
Agreement by members to adhere to ADFP Practice and Professional Protocols is a requirement of membership
but should not be construed as a basis for any legal liability of the ADFP to third parties. It is strictly a
condition for membership. The ADFP does not perform divorce financial planning services or take
responsibility for the divorce financial planning or other services offered by its individual members. Services
provided by members are provided independently of the ADFP and are completely their responsibility.
Implying otherwise is a serious offense and grounds for membership termination
___________________________________________
________________
Signature
Date
Thank you for submitting this application. We will process it as quickly as possible, and look forward to
having you as a member!
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