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:
Yes No
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?:
Yes No
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?:
Yes No
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?:
Yes No
If yes please provide details:
Do you intend to invest with others?:
Yes No
Are you or your spouse a politically exposed person?:
Yes No
Are any of your children, parents, in-laws, siblings or immediate family members, politically exposed persons?:
Yes No
By submitting this form, you consent to your personal information being collected, held, used and disclosed to any regulatory body or third party institution in order to verify the information, if necessary, and if required by law or any applicable regulation.
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.