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info@legacypointgroup.com
1000 Legacy Dr. Chicago, IL 60600
Name
First
Last
Email
Shipping Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
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Aruba
Australia
Austria
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Benin
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Bouvet Island
Brazil
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Cameroon
Canada
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Chad
Chile
China
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Cook Islands
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Panama
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Samoa
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Saudi Arabia
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Serbia
Seychelles
Sierra Leone
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Sint Maarten
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Slovenia
Solomon Islands
Somalia
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South Sudan
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Sri Lanka
Sudan
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Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Billing same as shipping
Yes
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Spouse Name
First
Last
Children Names & Ages (1 per line)
Any Outside Business?
Yes
No
If yes, what business?
Current Practice Owner?
Yes
No
Which of the following best describes your annual income?
$0 - $500,000
$500,000 - $1,000,000
$1,000,000 - $2,000,000
2,000,000+
How many Practices?
1
2
3
4
5
More than 5
Hobbies/Interests
Auto Racing
Astronomy
Baking
Birdwatching
Board Games
Camping
Chess
Collecting
Cooking
Dancing
DIY Home Improvement
Fashion Design
Fishing
Film and Cinema
Gaming
Gardening
Geocaching
Hiking
Horseback Riding
Knitting or Crocheting
Martial Arts
Meditation
Origami
Painting
Paragliding
Photography
Playing Chess
Playing Music
Pottery
Reading
Rock Climbing
Sailing
Scuba Diving
Skiing or Snowboarding
Surfing
Traveling
Volunteering
Wine Tasting
Writing
Yoga
Financial Interests
401(k) and IRA management
Asset allocation and diversification
Charitable giving and philanthropy
Cost-cutting strategies
Credit score improvement
Cryptocurrency trading
Day trading
Dividend investing
Emergency fund savings
Entrepreneurship
Estate planning and wealth transfer
Financial coaching and consulting
Financial empowerment and empowerment of others
Financial goal achievement
Financial goal setting
Financial independence and early retirement (FIRE)
Financial literacy and education
Financial security and stability
Frugal living and minimalism
Homeownership and mortgage planning
Insurance planning (e.g., life insurance, health insurance)
Investing in stocks and bonds
Managing debt
Passive income streams
Personal finance budgeting
Real estate investment
Retirement planning
Risk management
Saving for education (e.g., college fund)
Savings for specific financial goals (e.g., travel, home purchase)
Starting a business
Sustainable and ethical investing
Tax-efficient investing
Tax planning and optimization
Wealth preservation
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