Please complete the following information as it will help us complete your overall investment profile. This information will be required for opening an account.

Information submitted through this form is sent through a secure connection to our server to prevent electronic data theft. Please be assured that all information collected is strictly confidential and will not be released without your prior consent.

Referred By:  
 
Name and Address
Name SS#
Street Address Home E-mail
City State Zip
Home Phone Home Fax
Date of Birth  
 
Employment Information
Employer Work Phone
Street Address Business Fax
City State Zip
Position E-mail
 
Spousal Information
Name SS#
Employer Date of Birth
Emp. Address Work Phone
City State Zip
Position  
 
Children Social Security # Date of Birth  
1.
2.
3.
 
Tax Bracket 15%      28%     31%     35%     39.6%
 
Net Worth $ (exclusive of residence)
 
Liquid Assets $
 
Annual Income $
 
Investment
Experience		 Enter the number of years experience investing with:
     Equities        Bonds  
     Futures        Options  

Return Objective Select one:
Current Income
Capital Appreciation
Current Income & Capital Appreciation
 
Risk Profile Select a Primary Profile and, if applicable, a Secondary Profile:
  Conservative Primary Secondary
  Moderate Primary Secondary
  Aggressive/Speculative Primary Secondary
 
Additional Information
CPA Attourney
Bank Emergency Contact

Charting your course
Your answers to the following questions will be used to generate an asset allocation model that may be the most appropriate to help you achieve your stated goal, taking into account your investment horizon and tolerance risk.

Your investment objective summarizes the primary purpose of your account. It serves to define how assets should be managed. While asking yourself, “What do I want to accomplish?” Select the objective that best fits the purpose of your account:

Preserve asset value
 Generate high current income
 Achieve asset growth with moderate current income
 Achieve strong asset growth with nominal income
 Achieve maximum capital appreciation

Please check the box that indicates your response to the following statement: “I am comfortable with investments that may lose money from time to time, if they offer potential for higher returns.”

Strongly disagree
 Disagree
 Somewhat agree
 Agree
 Strongly Agree

Age is a very important determinant of portfolio selection. Please check your age in the box below.

35 or under
 36-45
 46-55
 56-64
 65 or over

Your investment time horizon is an important variable to consider when constructing your account. How long will it be before you begin making withdrawals?

0-1 year
 1-2 years
 2-4 years
 4-6 years
 More than 6 years

Once you begin taking withdrawals from your portfolio, how long will the money in the account have to last before it is depleted?

Lump sum
 Less than 1 year
 1-5 years
 6-10 years
 11 or more years

An assessment of your income requirements is essential in determining the appropriate assets allocation. Please check the box that best approximates the amount of CURRENT income your account needs to generate annually as a percent of your total income from all sources.

0-5%
 6-15%
 16-30%
 31-50%
 Over 50%

How long could you cover monthly living expenses with cash and investments you currently have on hand?

1 month or less
 1-3 months
 3-6 months
 6-12 monhs
 12 months or more

What is your outlook for your future income from sources other than investments over the next ten years?

It will greatly decrease
It will decrease, but not by much
 It will stay the same
 It will increase, but not by much
 It will greatly increase

Thank you for taking the time to answer these questions. Please send them to us by clicking on the submit button below.