Account Information Needed

Please complete the below list

Type of account

Personal Single Account Personal Joint Account Corporate Account Partnership Account Trust Account Custodian Account IRA Regular Account IRA Roth Account Simple IRA Account Money Purchase Account Profit Sharing Account

Account Qualifications

Margin

Options

Checking

Discretionary Account

Third Party Trading Authorization

 Activity of Account

More than 75 Trades Per Month Between 50 and 75 Trades Per Month Between 30 and 50 Trades Per Month Between 20 and 30 Trades Per Month Between 10 and 20 Trades Per Month Between 5 and 10 Trades Per Month Between 2 and 5 Trades Per Month Less than 2 Trades Per Month

Company Name

First Name

Last Name

Gender

Male Female

Work Phone

Cell Phone

Home Phone

Email Address

Fax Number

Address

State/Country

Zip

SS# or TID#

Date of Birth

Drivers License or Passport #

Resident of the USA

USA Resident Non USA Resident

Sate of Residence if other than listed address

Country of Residence if other than USA

Net worth

Greater than 10,000,000 $7,500,000 to $10,000,000 $5,000,000 to $7,500,000 $4,000,000 to $5,000,000 $3,000,000 to $4,000,000 $2,000,000 to $3,000,000 $1,500,000 to $2,000,000 $1,000,000 to $1,500,000 $750,000 to $1,000,000 $500,000 to $750,000 $400,000 to $500,000 $300,000 to $400,000 $250,000 to $300,000 $200,000 to $250,000 $150,000 to $200,000 $100,000 to $150,000 $50,000 to $100,000 less than $50,000

Assets

Greater than 10,000,000 $7,500,000 to $10,000,000 $5,000,000 to $7,500,000 $4,000,000 to $5,000,000 $3,000,000 to $4,000,000 $2,000,000 to $3,000,000 $1,500,000 to $2,000,000 $1,000,000 to $1,500,000 $750,000 to $1,000,000 $500,000 to $750,000 $400,000 to $500,000 $300,000 to $400,000 $250,000 to $300,000 $200,000 to $250,000 $150,000 to $200,000 $100,000 to $150,000 $50,000 to $100,000 less than $50,000

Securities (non IRA/401K)

Greater than 10,000,000 $7,500,000 to $10,000,000 $5,000,000 to $7,500,000 $4,000,000 to $5,000,000 $3,000,000 to $4,000,000 $2,000,000 to $3,000,000 $1,500,000 to $2,000,000 $1,000,000 to $1,500,000 $750,000 to $1,000,000 $500,000 to $750,000 $400,000 to $500,000 $300,000 to $400,000 $250,000 to $300,000 $200,000 to $250,000 $150,000 to $200,000 $100,000 to $150,000 $50,000 to $100,000 less than $50,000

Securities  (IRA/401K/Retirement Plans)

Greater than 10,000,000 $7,500,000 to $10,000,000 $5,000,000 to $7,500,000 $4,000,000 to $5,000,000 $3,000,000 to $4,000,000 $2,000,000 to $3,000,000 $1,500,000 to $2,000,000 $1,000,000 to $1,500,000 $750,000 to $1,000,000 $500,000 to $750,000 $400,000 to $500,000 $300,000 to $400,000 $250,000 to $300,000 $200,000 to $250,000 $150,000 to $200,000 $100,000 to $150,000 $50,000 to $100,000 less than $50,000

Assets in Real Estate

Greater than 10,000,000 $7,500,000 to $10,000,000 $5,000,000 to $7,500,000 $4,000,000 to $5,000,000 $3,000,000 to $4,000,000 $2,000,000 to $3,000,000 $1,500,000 to $2,000,000 $1,000,000 to $1,500,000 $750,000 to $1,000,000 $500,000 to $750,000 $400,000 to $500,000 $300,000 to $400,000 $250,000 to $300,000 $200,000 to $250,000 $150,000 to $200,000 $100,000 to $150,000 $50,000 to $100,000 less than $50,000

Assets in Cash or CD's

Greater than 10,000,000 $7,500,000 to $10,000,000 $5,000,000 to $7,500,000 $4,000,000 to $5,000,000 $3,000,000 to $4,000,000 $2,000,000 to $3,000,000 $1,500,000 to $2,000,000 $1,000,000 to $1,500,000 $750,000 to $1,000,000 $500,000 to $750,000 $400,000 to $500,000 $300,000 to $400,000 $250,000 to $300,000 $200,000 to $250,000 $150,000 to $200,000 $100,000 to $150,000 $50,000 to $100,000 less than $50,000

Income Total

Income Earned / W2 

Employee / Owner

Employee Self Employed Retired Student

Marital Status

Single Married Divorsed Separated

Spouse's Name

Spouse's SS#  or Passport#

Spouse's Date of Birth

Number of Children

0 1 2 3 4 5 6 7 8 9 10

Life Insurance

Term Universal Life Universal Variable Life Whole Life Do not have

Disability Insurance

Have through work Have a personal policy Have Long Term Care Policy Do not have

Health Insurance

Have through work Have Personal Policy Do not have

Education Funds

Greater than 10,000,000 $7,500,000 to $10,000,000 $5,000,000 to $7,500,000 $4,000,000 to $5,000,000 $3,000,000 to $4,000,000 $2,000,000 to $3,000,000 $1,500,000 to $2,000,000 $1,000,000 to $1,500,000 $750,000 to $1,000,000 $500,000 to $750,000 $400,000 to $500,000 $300,000 to $400,000 $250,000 to $300,000 $200,000 to $250,000 $150,000 to $200,000 $100,000 to $150,000 $50,000 to $100,000 less than $50,000

Investment Experience

More than 10 years Between 5 and 10 years Between 2 and 5 years Less than one year

Investment Knowledge

Excellent Very Godd Good Less than Average No Knowledge

Type of Investor

Aggressive Growth Growth and Income Aggressive Income Income

Risk Tolerance

High degree of risk Above average risk Average Risk Below Average No Risk

If known the name of your selected Financial Consultant

Life Insurance

I am interested in more information on the below checked items:

Disability Insurance

Health Insurance

Mortgage Financing

Managed Accounts

Private Funds

Private Placements

Annuities

IPO's

Stocks

Bonds

Options

Mutual Funds