Title
DR
MISS
MR
MRS
MS
First Name *
Last Name *
Work Phone Number *
Work Fax Number
Email Address *
Work Address *
City *
State *
Zipcode/Postcode *
Country *
-- Select Country --
AFGHANISTAN
ALAND ISLANDS
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTARCTICA
ANTIGUA AND BARBUDA
ARGENTINA
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOSNIA AND HERZEGOVINA
BOTSWANA
BOUVET ISLAND
BRAZIL
BRITISH INDIAN OCEAN TERRITORY
BRUNEI DARUSSALAM
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CAPE VERDE
CâTE D'IVOIRE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHILE
CHINA
CHRISTMAS ISLAND
COCOS (KEELING) ISLANDS
COLOMBIA
COMOROS
CONGO
CONGO, THE DEMOCRATIC REPUBLIC OF THE
COOK ISLANDS
COSTA RICA
CROATIA
CUBA
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FALKLAND ISLANDS (MALVINAS)
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
FRENCH SOUTHERN TERRITORIES
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HEARD ISLAND AND MCDONALD ISLANDS
HOLY SEE (VATICAN CITY STATE)
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN, ISLAMIC REPUBLIC OF
IRAQ
IRELAND
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF
KOREA, REPUBLIC OF
KUWAIT
KYRGYZSTAN
LAO PEOPLE'S DEMOCRATIC REPUBLIC
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYAN ARAB JAMAHIRIYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MACAO
MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF
MADAGASCAR
MALAWI
MALAYSIA
MALDIVES
MALI
MALTA
MARSHALL ISLANDS
MARTINIQUE
MAURITANIA
MAURITIUS
MAYOTTE
MEXICO
MICRONESIA, FEDERATED STATES OF
MOLDOVA, REPUBLIC OF
MONACO
MONGOLIA
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMIBIA
NAURU
NEPAL
NETHERLANDS
NETHERLANDS ANTILLES
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE
NORFOLK ISLAND
NORTHERN MARIANA ISLANDS
NORWAY
OMAN
PAKISTAN
PALAU
PALESTINIAN TERRITORY, OCCUPIED
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILIPPINES
PITCAIRN
POLAND
PORTUGAL
PUERTO RICO
QATAR
REUNION
ROMANIA
RUSSIAN FEDERATION
RWANDA
SAINT HELENA
SAINT KITTS AND NEVIS
SAINT LUCIA
SAINT PIERRE AND MIQUELON
SAINT VINCENT AND THE GRENADINES
SAMOA
SAN MARINO
SAO TOME AND PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA AND MONTENEGRO
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS
SPAIN
SRI LANKA
SUDAN
SURINAME
SVALBARD AND JAN MAYEN
SWAZILAND
SWEDEN
SWITZERLAND
SYRIAN ARAB REPUBLIC
TAIWAN, PROVINCE OF CHINA
TAJIKISTAN
TANZANIA, UNITED REPUBLIC OF
THAILAND
TIMOR-LESTE
TOGO
TOKELAU
TONGA
TRINIDAD AND TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TURKS AND CAICOS ISLANDS
TUVALU
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM
UNITED STATES
UNITED STATES MINOR OUTLYING ISLANDS
URUGUAY
UZBEKISTAN
VANUATU
VENEZUELA
VIETNAM
VIRGIN ISLANDS, BRITISH
VIRGIN ISLANDS, U.S.
WALLIS AND FUTUNA
WESTERN SAHARA
YEMEN
ZAMBIA
ZIMBABWE
Company
Retired? *
Yes
No
Age *
Portfolio objective *
Conservative: I want to use my portfolio to build wealth slowly while also preserving my principal.
Moderate: I need a balance of current income and growth of my principal. I can tolerate moderate fluctations in my portfolio in attempting to achieve my goals.
Aggressive: My objective is growth of my principal in the pursuit of maximizing returns in order to build wealth for my retirement years. I understand that the pursuit of this objective may entail a greater potential loss of principal.
Are you a high net worth investor? *
Yes
No
Experience *
Stock
Bonds
Options
Futures
Total Investment Size *
$10000 - $50000
$500000 - $1000000
$1000000 - $3000000
$3000000 - $5000000
How do you make your investment decisions? *
I closely watch the market and conduct my own research on mutual funds.
Watching the market is very enjoyable but burdensome and confusing.
I am a long term investor
no reason to make changes to my portfolio.
I have an investment advisor who helps me make decisions.
I do not have time to make investment decisions.
Describe your relationship with your current advisor (Check all that apply) *
I do not have an advisor but I am looking for one.
I do not have an advisor and I would not use one.
I do not have an advisor but I am interested in learning how one might help me with my investments.
I have a good relationship with my advisor I will work with him/her for years to come.
I have a good relationship with my advisor but I have another portion of my portfolio that help.
I have a poor relationship with my advisor.
How would you like us to help you with your portfolio? (Check all that apply) *
I need help improving my investment returns.
I do not have the time to monitor my portfolio.
I need to use my portfolio to supplement my income.
I understand that my portfolio deserves constant attention
but I do not want to spend the time monitoring it.
I am not interested in having someone manage my portfolio but would like your recommendations on what to buy and sell.
What types of accounts do you currently have, or are considering opening? (Check all that apply) *
IRA
Trust
Keogh
401(k)
403(b)
Joint Account
Corporate Account
I am primarily concerned about the following. (Check all that apply) *
Preservation of a significant lump-sum distribution from a sale
inheritance or bonus.
Reaction to unsettling market volatility.
Improving investment results.
Lack of time to manage portfolio effectively.
Require investment management due to untimely life event/survivorship issues.
IRA
401(k) or 403(b) account management.
Diversification into other asset classes such as gold funds or income funds.
Please let us know if you have any other questions or comments
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