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<br />tttrfl <br /> <br />U[Ut -.{ftUI..(Sf-ffI\-/ <br /> <br />.. <br /> <br />NORTHLAND~SECURITIES <br /> <br />Account Application <br />Account # l b r <br /> <br />I.E. Name & Number <br /> <br />1. AccOUNTTYPE <br />o Individual <br />o JT with Rights of Survivorship <br />o Custodial <br />o IT Tenants in Common <br /> <br />8 Trust <br />Corporate <br />o Non - Profit <br />o Estate <br /> <br />o Investment Club <br />o Partnership <br />o Traditional IRA <br />o IRA Rollover <br /> <br />2. ACCOUNT REGISTRATION <br />(J, (!erLkrvi lie- <br />er/Custodian (First, Ml, Last) <br /> <br /> <br />o Roth IRA <br />o SEP IRA <br />o Pension <br />cr:- Other: <br /> <br />111 lbtlr;{ {)Ci(,'-hJ. <br />{ 7 <br /> <br /> <br />'{ <br /> <br />'ff1-/::u,701 <br />S,Qei..dSwUlit)'# <br /> <br />Date of Birth <br /> <br />Joint ACCOlUlt OwnerlMinof) ifappticable (First. MI, Last) <br /> <br />Social Security # <br /> <br />Date of Birth <br /> <br />If Corporate, Trust, Inv. Club, etc., provide name of entity <br />ISW Ma.in Sf::vu:f <br /> <br />Home Address (physical Address Required) <br /> <br />Trustee(s) <br />(!D1kJ-v7/1-L I M IV <br />City I State <br /> <br />Trust Agreement Date . <br />5?{>3f- 779'1 <br />Zip <br /> <br />Mailing Address (p.D. Box acceptable) <br /> <br />City <br /> <br />Zip <br /> <br />State <br /> <br />Home Phone Number <br /> <br />Fax Number <br /> <br />I 3. CLIENT PROFILE <br />Marital Status: 0 Single 0 Married 0 Divorced 0 Widowed <br /> <br />Email Address <br /> <br /> <br />o U.S Citizen <br /> <br />Imot a U.S. Citizen, state country of Ciiizenship and indicate cJassific on (mandatory): Country <br />o U.S. Permaoent Resident 0 Resident Alien 0 Non-Resid Alien (Substitute Wo81orm required) <br />EmpJorment Information (Iftlnemplayed, retired, homemaker or student, pJeas <br /> <br /> <br />Applicant's Occopatioo <br /> <br />Employer Name and Address <br /> <br />Co-Applicant's Occupation <br /> <br />Investment EXDerience Years <br />Equities <br />Taxable Bonds <br />Tax-Free Bonds <br />Mutual Funds <br />Other <br /> <br />Business Phone Number <br /> <br />Business Phone Number <br /> <br />Risk Tolerance <br />o Conservative <br />o Moderate <br />o Aggressive <br />o Speculative <br /> <br /> <br />Financial Information: (Se <br /> <br />Est. Annual Iiicome <br />o Under $25,000 <br />o $25,000 0 $49,92 <br />o $50,000 - $99 9 <br />o $100,000 - $ 50,000 <br />o Over $250,600 <br /> <br />ities Industry regulations require that we obtain the fol/owing information) <br /> <br />Est. Net Worth lexcludin~ residence) Est. Liauid Net Worth <br />o Under $50,000 0 Under $50,000 <br />. 0 $50,0000$99,999 0 $50,0000 $99,999 <br />o $100,000 - $499,999 0 $100,000 - $499,999 <br />o $500,000 - $999,999 0 $500,000 - $999,999 <br />o Over $1,000,000 0 Over $1,000,000 <br /> <br />Federal Tax Rate <br />o 15% <br />o 28% <br />o 31% <br />o 36% <br />o 39.6% <br />