Please upload a headshot of yourself:
First name:
Mobile phone number:
Business phone number:
Email:
Date of birth:
Social Insurance Number:
Social Security Number:
Citizenship:
Place of residence:
Proof of Residency(upload utility bill or idenitifcation with your address and name):
Mailing address:
Business Address:
Image of Passport:
Passport Number:
Passport Date of Issue:
Image of Driver's License:
Driver's License Number:
Driver's License Date of Issue:
Image of Identification Card:
I.D. Card Number:
I.D. Card Date of Issue:
Proof of Income (upload image of recent income tax filings or pay stubs):
Proof of Banking (upload image of cheque or bank statement):
Occupation:
Self employed:
Employer:
Place of employment:
Type of business:
Gross Annual Income: Select Under $50,000 $50,000 - $99,999 $100,000 - $199,999 $200,000 - $399,999 $400,000 - $599,999 $600,000 - $1 million Over $1 million
Networth: Select Under $50,000 $50,000 - $99,999 $50,000 - $99,999 $200,000 - $399,999 $400,000 - $599,999 $600,000 - $999,999 $1 milllion - $1,999,999 $2 million - $4,999,999 $5 million - $9,999,999 Over $10 million
Investment knowledge: Select Poor/Nil Novice Fair Good Sophisticated
Time horizon: Select Lessthan1year 1tolessthan3years 3tolessthan5years 5tolessthan10years 10tolessthan20years Over20years
Risk tolerance: Select High Moderate Low
Investment objectives: Select Income Growth Speculation
Source of funds to invest with: Select Employment/WagesIncome InvestmentIncome Gift/Inheritance Savings/RetirementFunds SaleofAsset,HomeorBusiness
Marital status: Select Single Married Divorced Widowed
Number of dependents:
Spouse's first name:
Spouse's last name:
Spouse's date of birth:
Spouse's occupation:
Spouse's employer:
Spouse's place of employment:
Spouse's social insurance number:
Spouse's social security number:
Spouse's gross annual income: Select Under $50,000 $50,000 - $99,999 $100,000 - $199,999 $200,000 - $399,999 $400,000 - $599,999 $600,000 - $1 million Over $1 million
Spouses networth: Select Under $50,000 $50,000 - $99,999 $50,000 - $99,999 $200,000 - $399,999 $400,000 - $599,999 $600,000 - $999,999 $1 milllion - $1,999,999 $2 million - $4,999,999 $5 million - $9,999,999 Over $10 million
Do you alone or as part of a group own 10% or more of the voting shares or units in a publicly traded entity?:
If yes, please provide details:
Are you a director or executive officer of an entity whose shares or units are traded on an exchange or OTC?:
If yes, please provide details:
Are you, your spouse or any member of your household an employee, director, officer or partner of a securities dealer, or of a stock exchange itself or a securities regulatory body?:
If yes please provide details:
Do you intend to invest with others?:
Are you or your spouse a politically exposed person?:
Are any of your children, parents, in-laws, siblings or immediate family members, politically exposed persons?:
By submitting this for you certify that the information provided is true, accurate and complete, and the recipient may rely thereon until you send written notice of any significant changes.
