IRA Information Request Form

In order for us to provide you with appropriate financial advice, we ask you to complete the form below.

Please provide the following information:

Name

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Country

Work Phone

Home Phone

FAX

E-mail

If this information is for husband and wife please fill out:

Husband:

Name

Date of birth

Wife:

Name

Date of birth

Select any of the following that you would like more information on:

Traditional IRA  Roth IRA         Other

If "other" please explain:

Privacy Statement:

We are dedicated to serving our Customers’ needs for privacy as well as for creating products that they might find valuable. We do Not share our Customer’s non-public personal information with nonaffiliated companies except as otherwise permitted or required by law. We will not reveal our Customer information to any external organization unless we have previously informed our Customer in this or other disclosures or agreements, have been authorized by our Customer, or are otherwise required by law.

Disclaimer:

By giving my phone number I understand that I am giving permission for you to contact me and this waives my right to the National Do-Not-Call list whether my telephone number appears now or I subsequently add my telephone number(s) to the National or State list.

Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail

IRA Information Request Form

Last revised: September 20, 2004