Agent Marketing Resources · For Independent Brokers & Captive Agents

Pamphlet Personalization Request

Fill in this form and press Submit request, or download it as a PDF and send it back. Fill in this form, save it and send it back. We add your details and your QR code to the pamphlets.

Your information

As you want it printed

Full name

Designationse.g. CLTC, CFP

Company or agency (optional)

Title (optional)

Phone

Website (optional)

Licensing statement e.g. Licensed in FL and IL

Short professional description (one line)About 90 characters

License number / NPN (optional, shown in small print)

Your personal QR code

Leave the link blank and your QR code will save your name, phone and email straight to the reader's phone. Or enter a link, such as your scheduling page or website, and the QR code will open it.

QR code link (optional)Leave blank for a contact card

Pamphlets you want personalized

Check all that apply

Pamphlets you want personalized My Wishes, My Plan: Parent Guide (10 pages) Questions to Ask Your Parents (11 pages)

Approval

I confirm this information is accurate and that I am licensed where my licensing statement says. Any claim about my standing (such as awards, rankings or “expert” status) can be supported and meets my state's advertising rules. I approve the pamphlets for use with my details once I review the proof.

Signature (type your name)

Date

Return this form to Kim Purnell · Adaptive Marketing Group · (321) 795-7516

The pamphlets are educational. Your details appear on the cover and in a contact card with your QR code. Nothing in them collects information for anyone else. You will receive a proof to review before printing. Print files are 8.5 x 11 with a 0.125 in. bleed.

Fields marked * are needed to submit. The PDF download keeps everything you typed, and you can keep editing it in any PDF reader.

Contact Kim