Individual Account Application - US Citizens

Account Name

Date of Birth

Social Security Number

Marital Status

Single
Divorced
Married
Widowed

E-mail Address

Home Address - Enter your entire home address including city, state, and zip code.

Home Telephone

Employer

Years Employed

Position

Business Address

Business City

Business State

Business Zip

Business Telephone

Mailing Address (if different from home address)

Where do you want your statements mailed to?

Home
Business
PO Box

Have you granted trading authorization to another party?

Yes
No

If yes, please proved the name of the trading authorization agent

Is the account holder a control person of a publicly traded company? (Director, Officer or 10% Stock Owner)

Yes
No

If yes, please list the name of the company(s) and the stock ticker symbol.

Are you. or anyone authorized to trade in your account, affiliated with or work with or work for a member form of a stock exchange or FINRA?

Yes
No

If yes, please provide the name of the firm:

Name of your bank

Type of account that you have at your bank

select

Provide the last 4 digits of your bank account

Describe your investment objectives.

Speculation
Income
Growth
Capital Preservation
Other

Describe your investment experience

None
Limited
Good
Extensive

What is your annual income?

Under $25,000
$25,001 to $50,000
$50,001 to $100,000
$100,001 to $200,000
$200,001 to $300,000
$300,001 to $500,000
$500,001 to $1,200,000
Over $1,200,001

What is your liquid net worth? (cash & liquid investments only)

Under $50,000
$50,001 to $100,000
$100,001 to $200,000
$200,001 to $500,000
$500,001 to $1,00,000
$1,000,001 to $5,000,000

What is your total net worth excluding your residence?

Under $50,000
$50,001 to $100,000
$100,001 to $200,000
$200,001 to $500,000
$500,001 to $1,00,000
$1,000,001 to $5,000,000

What is your risk tolerance?

High
Medium
Low

What tax bracket are you in?

select

Number of dependents

Rule 14b-1(c) of the Securities Exchange Act, unless you object, requires us to disclose to an issuer, upon its request, the names, addresses, and securities positions of our customers who are beneficial owners of the issuer’s securities held by us in nominee name. The issuer would be permitted to use your name and other related information for corporation communication only. If you object to this disclosure check the box.

Yes, I do object to the disclosure of such information.

Is the account maintained for a current or former Politically Exposed Person or Public Official (includes U.S. and Foreign Individuals)?

Yes
No

If yes, please provide the names of that official and official's immediate family members (including former spouses).

If yes, please provide the name of the related political organization.

Is the account maintained for a Foreign Financial Institution as defined by Title 30 of the Code of Federal Regulations? If yes, please complete the "Foreign Financial Institution Due Diligence Questionnaire" form.

Yes
No

Is this account a Foreign Bank organized under foreign law and located outside of the United States as defined by Title 31 of the Code of Federal Regulations? If "yes", please ensure the "Certification Regarding Correspondent Accounts" is complete (in addition to the "Foreign Financial Institution Due Diligence Questionnaire" form). NOTE: Broker-dealers are prohibited from establishing, maintaining, administering or managing correspondent accounts in the United States for foreign shell banks. The prohibition does not include foreign shell banks that are regulated affiliates.

Yes
No

How were you referred to Glendale Securities, Inc.?

select

Please describe "Broker" or "Other" referral sources

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