| * (Check Only One) |
|
|
|
| Individual ___ |
Sole Proprietorship ___ |
Joint Tenants (JTWROS) ___ |
|
| Corporation ___ |
General Partnership ___ |
|
|
| CUSTOMER INFORMATION |
|
| Account Owner Name: _______________________________________ |
Date of Birth: __________________ |
|
| Account Owner Name: _______________________________________ |
Date of Birth: __________________ |
|
|
|
Address: _________________________________________________________________________________ |
|
Mailing Address for all Notices and Statements (No PO Box for FedEx) |
|
|
| City: _____________________ |
State: _____________________ |
Zip Code: _____________________ |
|
| Telephone: ________________ |
Office: ____________________ |
Fax: _________________________ |
|
| Employer's Name: ___________________________ |
Position: _____________________________________ |
|
|
|
Employer's Address: ________________________________________________________________________ |
|
| City: ______________________ |
State: _____________________ |
Zip: __________________________ |
|
Social Security # or Tax I.D. #:
__________________________ |
Citizenship:
__________________________ |
Country of Residence:
_____________________________ |
|
| E-Mail Address: ____________________________________________________________________________ |
|
| FINANCIAL INFORMATION |
|
| Bank Name: _______________________________ |
Branch Location: ______________________________ |
|
|
| Annual Income : |
|
| ___ $100,000-$250,000 |
___ $250,000-$500,000 |
___ $500,000-$1,000,000 |
___ Over $1,000,000 |
|
|
| Net Worth : |
|
| ___ $100,000-$250,000 |
___ $250,000-$500,000 |
___ $500,000-$1,000,000 |
___ Over $1,000,000 |
|
|
| Liquid Net Worth: |
|
| ___ $100,000-$250,000 |
___ $250,000-$500,000 |
___ $500,000-$1,000,000 |
___ Over $1,000,000 |
|
|
| Investment Objectives: |
|
| ___ Growth |
___ Speculation |
___ Income |
___ Hedge |
___ Conservation of Capital |
|
|
| Investment Experience: |
|
| Number of Years ________________ |
|
|
The undersigned hereby attest(s) and certifies to be
sophisticated financial institution and/or sophisticated participant and
attest(s) the above information is complete and accurate. The undersigned hereby
authorizes LAM to verify any or all of the foregoing
information. |
|
|
|
|
| _____________________________________ |
Date: ______________________________ |
|
|
|
|
|
| _____________________________________ |
Date: ______________________________ |
|
|
|
This Document and Signature received by either, facsimile and/or mail shall be deemed to be an original executed application.
|
+1 416 860 6213
