Registry Member Application
1) CLIENT / SPOUSE PERSONAL INFORMATION
Client:
  M
Yes No
First Name MI Last Name
DOB F
      U.S. Citizen
Spouse:
  M
Yes No
First Name MI Last Name
DOB F
      U.S. Citizen
Address:
Street Address (or P.O. Box No.) Unit
City
County/Parish State
Zip Code
Contact:
Daytime Phone Other Phone
E-mail Address
2) NATURAL-PERSON BENEFICIARIES
Male
First Name MI Last Name Age Female   Relationship Share
Male
First Name MI Last Name Age Female   Relationship Share
Male
First Name MI Last Name Age Female   Relationship Share
Male
First Name MI Last Name Age Female   Relationship Share
Male
First Name MI Last Name Age Female   Relationship Share
Male
First Name MI Last Name Age Female   Relationship Share
Male
First Name MI Last Name Age Female   Relationship Share
3) DISTRIBUTIONS TO CONTINGENT BENEFICIARIES

Select the appropriate provision designating to whom the share of any Primary Beneficiary (PB) - as are identified above - who may not survive you shall be distributed to as a Contingent Beneficiary(s).

EQUALLY to PB's surviving children - or, if PB leaves no surviving children, then equally to PB's surviving siblings (or to remaining Primary Beneficiaries).

EQUALLY to PB's surviving siblings (or to remaining Primary Beneficiaries) - or, if PB leaves no surviving siblings (no remaining Primary Beneficiaries), then equally to PB's surviving children.

4) ADMINISTRATORS OF YOUR TRUST
If you are married, it is assumed that your spouse will serve as the administrator of your estate. 
  Select a Corporate Trustee as the Primary Successor Trustee
  Select a Natural Person(s) as the Primary Successor Trustee
1)
First NameInitialLast Name Relationship
2)
First NameInitialLast Name Relationship
3)
First NameInitialLast Name Relationship
5) PERSONAL HEALTH CARE AGENT APPOINTEES
If you are married, it is assumed that your spouse will serve as your Primary Health Care Agent, if able, before the appointees listed below.
Client's Appointments:
1) /
First Name Initial Last Name Relationship
2) /
First Name Initial Last Name Relationship
Spouse's Appointments:
1) /
First Name Initial Last Name Relationship
2) /
First Name Initial Last Name Relationship
6) GUARDIAN APPOINTEES FOR DEPENDENT CHILDREN
1) /
First Name Initial Last Name Relationship
2) /
First Name Initial Last Name Relationship