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Client Data Form

The information gathered in this form helps us comply with various securities regulations and the USA PATRIOT Act, a Federal law that requires all securities firms to obtain, verify and record information that identifies each applicant. The information also helps us more fully understand your investment profile and identity what types of investments or strategies may be suitable for you.

Step 1 of 5

Date
MM slash DD slash YYYY
Name*
First Middle Last
CONTACT INFORMATION
Legal Address*
Street Address Apt / Suite / Unit / # City State / Province / Region ZIP / Postal Code Country
Mailing Address - (if using a P.O. Box or different than legal address)
Street Address Apt / Suite / Unit / # City State / Province / Region ZIP / Postal Code Country

If using a P.O. Box or different than Legal Address
Cell Phone*
Home Phone*
Work Phone*
Email*
Preferred Contact Method*
Preferred Contact Time*
USA Patriot Act Info
Required by Federal Law. All Applicants please provide the information below. Non-resident aliens, also include a completed W-8BEN. All new applicants please provide a copy of your ID.
Date of Birth*
SSN
Country of Citizenship
Type of ID
Issued by U.S. State ( if not U.S. - Country of Issue)
ID Issue Date
MM slash DD slash YYYY
ID Expiration Date
MM slash DD slash YYYY
FAMILY INFORMATION
Marital Status
Spouse Name
First Last
Number of Dependents

EMPLOYMENT INFORMATION
Employment Status
Job Title/ Occupation
Employer
Years with Employer
Work Phone
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
TRUSTED CONTACT INFORMATION
Must be 18+ years old
Trusted Contact
Required to enter a Trusted Contact. If applicable, add rows for your Attorney's and/or Account's contact info. If you wish to decline, please check the box next to "I decline".
Name/Relation Phone Email Address Age
I DECLINE TO PROVIDE A TRUSTED CONTACT
- I Decline

INDUSTRY & OTHER AFFILIATIONS
Are you, your spouse or any other immediate family member, including parents, in-laws, siblings and dependents:
1. Employed by or associated with the Securities Industry (for example, a sole proprietor, partner, officer, director, branch manager, registered representative or other associated person of a broker-dealer firm) or a financial services regulator?
- Yes
- No
-
If yes, specify entity below. If this entity requires its approval for you to open this account, please provide a copy of the required authorization letter (with this Application)
If yes, Name of Entity(ies)
If yes, Name of Entity(ies)
2. An Officer, director or 10% (or more) shareholder in a publicly-owned company?
- Yes
- No
If yes, name of company and symbol:
If yes, name of company and symbol:
3. A senior military, governmental or political official in a non-US country?
- Yes
- No
If yes, name of country
If yes, name of country

FINANCIAL SITUATION
Please provide your best estimates for the following
Annual Income
includes income from sources such as employment, alimony, social security, investment income, etc.
Net Worth
is the value of your assets minus your liabilities. For purposes of this application, assets include stocks, bonds, mutual funds, other securities, bank accounts, and other personal property. Do not include your primary residence among your assets. For liabilities, include any outstanding loans, credit card balances, taxes, etc. Do not include your mortgage.
Liquid Net Worth
is your net worth minus assets that cannot be converted quickly and easily into cash, such as real estate, business equity, personal property and automobiles, expected inheritances, assets earmarked for other purposes, and investments or accounts subject to substantial penalties if they were sold or if assets were withdrawn from them.
Tax Rate
State & Federal Combined
Annual Expenses
might include mortgage payments, rent long-term debts, utilities, alimony or child support payments, etc.
Liquidity Needs
annual cash requirement

FINANCIAL INVESTMENT EXPERIENCE
We are collecting the information below to better understand your investment experience. This would include the years you or someone on your behalf has been investing for you. We recognize your responses may change over time as you work with us.
Individual Stocks
Bonds
Options
Alternative
Mutual Funds/ Exchange Traded Funds
Annuities
Other Investments
Please provide us with additional information about your other investments to help us more fully understand your investment profile and identify what types of investments or strategies may be prudent for you.
Investment type/ Description Firm holding the investment Amount ($US)

Investment type/ Description	Firm holding the investment	Amount ($US)

Name/Relation	Phone	Email	Address	Age

Client Data Form

Client Data Form

Step 1 of 5

CONTACT INFORMATION

USA Patriot Act Info

FAMILY INFORMATION

EMPLOYMENT INFORMATION

TRUSTED CONTACT INFORMATION

INDUSTRY & OTHER AFFILIATIONS

FINANCIAL SITUATION

FINANCIAL INVESTMENT EXPERIENCE