APPLICATION FORM

Print out a copy of the application form below, and mail it along with your check to:

         Association of Counselors for Equity Securities, Inc

        3100 Gaylord Avenue

       Pittsburgh,Pennsylvania 15216 2420

People have a habit of changing things without telling everyone else about the change. That is why we need every means of contacting you.

Your Name   Mr.  Ms.  _________________________________

Home address       # and Street   _________________________________________

                              City, State, and Zip Code  _______________________________

Home Telephone Number  ______________________

Work Telephone Number  ______________________

Email Address  _____________ @ _________ . ______

Dat eof Birth  ___ / ___ / ___

Retirement Age _________