ADDRESS ___________________________________    PHONE (D) ________________

CITY/STATE _________________________________   PHONE (E) ________________

COUNTRY/ZIP _______________________________    FAX     ___________________

Mothers Maiden Name __________________________    EMAIL ___________________

Social Security Number __________________________   Birth Date ____/_____/_______
 

Please answer as fully as possible the following questions. Feel free to communicate any additional information you consider relevant.

1. If you are an experienced investor, how long have you been investing? ______ years.

Investments you have made. Check all that apply:

___ US Stocks ____ Mutual Funds ___ Taxable Bonds ___ Tax free Bonds ___ Foreign Stocks ___ Short Sales ___ Options ___ Futures ___ Partnerships. ___ Commodities ___ Other(s) ____________________________________________

2. Which best describes your overall attitude toward investment risk?

___ Strongly risk adverse - I want only VERY safe investments.

___ Risk adverse - I do not feel comfortable with risk.

___ Mild risk tolerance - I am willing to take an a occasional risk for above average gain

___ Risk taker - I am willing to take risks with a favorable risk/reward ratio.

___ Strong risk taker - I am willing to lose substantial portion of principle in order to GREATLY - increase the value of my investment.

3. What are your primary investment objectives? Check all that apply:

____ Capital preservation ___ Income ___ Tax Savings ___ Growth ___ Liquidity

4. What are your you main financial goals?

____ To be able to retire comfortably

____ To provide for the higher education cost for my child(ren)

____ To have adequate income if I should become disabled

____ To provide sufficient income for my survivors in the event of my death

____ __________________________________________________________________

____ __________________________________________________________________

5. Please include annual profit goals and risk tolerance for Funds to be managed by us.

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6. How did you hear of us __________________________________________________

7. Any comments or additional information you wish to provide:

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8. If we reach or exceed our agreed upon targets, may we use you as a reference?

____ Yes ____ No If Yes, ___ off the record or ___ publicly?

Please include copies of recent brokerage statement(s) you wish us to review.

PRIVATE CLIENT DATA

NAME ______________________________________________________________

Birthdate ______/______/______ Time * _______ AM/PM Place _______________

*As known. List source ( ) Birth Certificate ( ) Other

Current Vocation __________________________________________________

1) Have you used money manager other than mutual Funds in the past? ( ) Yes ( ) No

If yes, briefly indicate your relevant recent results with managed Funds:

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2) Any past experience with Financial Astrology: ( ) Yes ( ) No If yes, describe briefly:

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3) Primary Time Horizon: ___ Short Term ___ Intermediate Term ___ Long Term

4) Any comments or additional information you wish to provide:

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Please fill out this net worth statement ONLY if we are doing a full financial review and you do not have a current net worth statement to supply. Remember to include recent statements of any stock, bond, mutual fund, options and future accounts.