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| Individual ___ |
Sole Proprietorship ___ |
Joint Tenants (JTWROS) ___ |
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| Corporation ___ |
General Partnership ___ |
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| CUSTOMER INFORMATION |
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| Account Owner Name: _______________________________________ |
Date of Birth: __________________ |
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| Account Owner Name: _______________________________________ |
Date of Birth: __________________ |
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Address: _________________________________________________________________________________ |
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Mailing Address for all Notices and Statements (No PO Box for FedEx) |
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| City: _____________________ |
State: _____________________ |
Zip Code: _____________________ |
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| Telephone: ________________ |
Office: ____________________ |
Fax: _________________________ |
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| Employer's Name: ___________________________ |
Position: _____________________________________ |
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Employer's Address: ________________________________________________________________________ |
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| City: ______________________ |
State: _____________________ |
Zip: __________________________ |
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Social Security # or Tax I.D. #:
__________________________ |
Citizenship:
__________________________ |
Country of Residence:
_____________________________ |
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| E-Mail Address: ____________________________________________________________________________ |
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| FINANCIAL INFORMATION |
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| Bank Name: _______________________________ |
Branch Location: ______________________________ |
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| Annual Income : |
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| ___ $100,000-$250,000 |
___ $250,000-$500,000 |
___ $500,000-$1,000,000 |
___ Over $1,000,000 |
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| Net Worth : |
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| ___ $100,000-$250,000 |
___ $250,000-$500,000 |
___ $500,000-$1,000,000 |
___ Over $1,000,000 |
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| Liquid Net Worth: |
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| ___ $100,000-$250,000 |
___ $250,000-$500,000 |
___ $500,000-$1,000,000 |
___ Over $1,000,000 |
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| Investment Objectives: |
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| ___ Growth |
___ Speculation |
___ Income |
___ Hedge |
___ Conservation of Capital |
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| Investment Experience: |
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| Number of Years ________________ |
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The undersigned hereby attest(s) and certifies to be
sophisticated financial institution and/or sophisticated participant and
attest(s) the above information is complete and accurate. The undersigned hereby
authorizes LAM to verify any or all of the foregoing
information. |
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| _____________________________________ |
Date: ______________________________ |
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| _____________________________________ |
Date: ______________________________ |
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This Document and Signature received by either, facsimile and/or mail shall be deemed to be an original executed application.
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001 905 361-2896
