I. PERSONAL INFORMATION
NAME__________________________________________________
ADDRESS_______________________________________________
SOC. SEC. or TAXPAYER ID#__________________TELEPHONE:(HOME)_______________
Account number:__________________________________
Marital Status:______Single_____Married______Other:_____
Number of Dependents:____
AGE:____
Occupation:____________________________Position:_________________________
Employer:______________________________Address:________________________
Years with current employer:__________________If less than two years,
name of previous employer:_______________________________
Education:(Check all that apply)
_____________ High School
_____________ College
_____________ Advance college Degree(s)
FINANCIAL SITUATION
Estimated annual income from all sources:
___ Below $20,000 ___ $20,000 to $35,000
___ $35,000 to $50,000 ___ $50,000 to $100,000
___ $100,000 to $200,000 ___ Over $200,000
Estimated new worth (excluding primary residence): (check one)
___ Below $50,000 ___ $50,000 to $100,000
___ $100,000 to $500,000 ___ $500,000 to $1 million
___ Over $1 million
Estimated liquid net worth (cash, equity securities, bonds, etc.:)
Check one:
__ Below $10,000 ___ $10,000 to $25,000
___ $25,000 to $50,000 ___ $50,000 to $100,000
___ Over 100,000
Source of Annual Income (as a % of total income):
Employment Compensation _____%
Investment Income _____%
Other (please specify: _____________________ )_____%
New Account? ___ Yes ___ No
If no, date account opened:________________
Sources of Information for Section I above: (check one)
___ Customer
___ Other (please specify):________________
II. INVESTMENT OBJECTIVES AND EXPERIENCE
Investment Objectives:( If more than one, give order of importance with "1" being most important. )
___ Income (Cash-generating, high dividend stocks and bonds)
___ Growth (Long-term capital appreciation)
___ Safety of Principal/Income (Protection of investment plus income)
___ Safety of Principal/Growth (Protection of investment plus growth)
___ Speculation (High risk of loss)
___ Trading Profits
___ Other (please specify):_________
INVESTMENT EXPERIENCE:
TYPE YEAR OF USUAL DOLLARS NUMBER TYPE
EXPERIENCE INVESTED PER TRADES PER ACCT.
TRADE YEAR C/M*
----------- ---------------- --------------------- ----------------- ----------------
Non-Nasdaq/
non-exchange
stocks < $3
per share ____________ _______________ ___________ ___________
Other stocks
priced < $5
per share ____________ _______________ ___________ ___________
Stocks ____________ _______________ ___________ ___________
Bonds ____________ _______________ ___________ ___________
Options ____________ _______________ ___________ ___________
Commodities ____________ _______________ ___________ ___________
Other(specify): ____________ _______________ ___________ ___________
_________________________ _______________ ___________ ___________
_________________________ _______________ ___________ ___________
*Type of Account: Designate C for Cash, M for Margin.
Source of Information for Section II above: (check one)
____ Customer
____ Other (please identify):_________________
Do you understand that you may lose your entire amount invested in your Designated Security purchase?
___Yes ___No
III. INVESTMENT ADVISER (If now applicable, check here__).
If there is no Investment Adviser for this account, check the box above and proceed to Section IV below. If you have retained an independent adviser to assist you in evaluation of the purchase of Designated Securities in this account, please provide the following information:
Name of Adviser_____________________________________________
Business Address_____________________________________________
Business Telephone___________________________________________
Credentials/Experience (to extent known by customer)__________________
Length of Time Adviser Has Advised Customer_______________________
IV. OTHER INFORMATION
Customer may provide any other information he or she deems relevant to his or her financial status, investment objectives, or investment experience. Attach additional sheets if necessary.
_________________________________________________________________________________
_________________________________________
V. SUITABILITY DETERMINATION
Dear Customer,
Based on the information provided in Section I through IV above, regarding your financial situation, investment objectives, and investment experience, for the reasons set forth below, we have determined that
transactions in Designated Securities are suitable for you. In addition, we have determined that you have sufficient knowledge and experience in financial matters to be capable of evaluating the risks of transactions in Designated Securities. The following analysis is the basis for this evaluation: (MUST BE COMPLETED)
______________________________________________________________________
Signature of Principal of Firm Date
UNDER SECURITIES AND EXCHANGE COMMISSION RULES 15G, IT IS UNLAWFUL FOR US TO EFFECT THE SALE OF DESIGNATED SECURITIES TO YOU UNLESS WE HAVE RECEIVED FROM YOU, PRIOR TO THE TRANSACTION, A WRITTEN AGREEMENT TO THE TRANSACTION.
WE ARE REQUIRED TO PROVIDE YOU WITH THIS STATEMENT AS TO THE SUITABILITY OF TRANSACTIONS IN DESIGNATED SECURITIES FOR YOU. PLEASE READ VERY CAREFULLY. YOU SHOULD NOT SIGN AND RETURN THIS STATEMENT IF IT DOES NOT ACCURATELY REFLECT YOUR FINANCIAL SITUATION, INVESTMENT OBJECTIVE, AND INVESTMENT EXPERIENCE, OR IF YOU DO NOT UNDERSTAND THE BASED SET FORTH ABOVE, OF OUR DETERMINATION THAT TRANSACTIONS IN DESIGNATED SECURITIES ARE SUITABLE FOR YOU.
I CERTIFY THAT THE FOREGOING IS TRUE, CORRECT AND ACCURATE:
Signature of Customer(s)__________________________________Date:_______________
Printed Name_____________________________________________________________
Signature of Customer(s)__________________________________Date:_______________
Printed Name_____________________________________________________________
Comments:_______________________________________________________________
Note: Do not return this completed form to the brokerage firm via facsimile transmission or any other form of electronic transfer. The Firm must have the original copy of this form before it can effect transactions in Designated Securities.
___ Original signed copy to be filed in customer account file.
___ A copy of this document to be placed in Designated Securities control file.
___ Customer copy.