BROKERAGE ACCOUNT APPLICATION

Reset Form
BROKERAGE ACCOUNT APPLICATION
Select an Account:
Joint - type:
Partnership - type:
Custodial
Individual
Trust
Estate
Print Form
IRA - type:
Corporate - type:
Qualified Plan - type:
Conservator/Guardianship
Applicant
Information about the primary account holder - depending on the account type, this may be
the minor, protected person, or organization (trust, corporation, partnership, etc.).
Name of Individual/Organization - if an individual, list first, middle & last names
Mr.
Mrs.
Ms.
Primary Physical Address no P.O. boxes or mail receiving/incorporation services
State
City
ZIP plus 4
Coverdell ESA
Investment Club
Update Acct #:
Non-Corporate Org
Co-Applicant
Information about the secondary account holder - depending on the account type, this may
be a custodian, trustee, trading officer/partner, or other authorized representative.
Name
First
Mr.
Mrs.
Ms.
Middle
Last
Primary Physical Address no P.O. boxes or mail receiving/incorporation services
State
City
(legal residence)
Account Mailing Address
How did you hear
about us?
Internet
TV/Radio Ad
Print Ad
News Article
Already a Client
Refer/Promo Code:
ZIP plus 4
(legal residence)
if different from home address; P.O. boxes may be used
Account Email Address
Phone
Home
check
preferred
Cell
Social Security/Tax ID # Date of Birth
Citizenship Information
Phone
Work
check
preferred
Are you a U.S. citizen?
No - complete
next section
Yes - skip to
employment
Country of citizenship:
Are you a permanent
U.S. resident?
Home
Cell
Work
Social Security/Tax ID # Date of Birth
Are you a U.S. citizen?
No - complete
next section
Yes - skip to
employment
Citizenship Information
Country of citizenship:
Are you a permanent
U.S. resident?
Yes - Alien Registration Number:
No*- Visa type:
Yes - Alien Registration Number:
No*- Visa type:
*If you will be in the U.S. 183 days or less, contact our International Department for assistance. *If you will be in the U.S. 183 days or less, contact our International Department for assistance.
Employment
Employed - list occupation:
Unemployed
Self-employed
Employment
Homemaker
Student
Employed - list occupation:
Unemployed
Self-employed
Retired
Employer
Employer
Employer Address
Employer Address
list occupation if self-employed
Homemaker
Student
Retired
list occupation if self-employed
Yes
No Is any applicant employed by or affiliated with a securities firm, a securities exchange, or FINRA?
Yes
No Is any applicant a control person or affiliate of a public company as defined by the SEC? This would generally include
If yes, provide organization name and compliance department address:
10% shareholders, members of the Board of Directors, and policy-making officers. If yes, provide company's trading symbol and name:
Yes
No Is any applicant, member of immediate family, or business associate a senior foreign political official?
Is this an Online Trading Account?
Yes - Trade confirmations and monthly account statements are posted electronically.
To receive paper copies, log into your account and access the "My Account" tab to change your document delivery settings (fees may apply).
Mail or
Hold
No - Non-Internet commissions apply. Trade confirmations and monthly account statements are mailed free of charge. Sales Proceeds:
Mail or
Dividends & Interest:
Hold
Margin - sign Margin section below. Not available for IRAs, Custodial accounts, Coverdell ESAs, Conservatorships, Guardianships or Estate accounts.
Additional Services
Options - complete an Options Application**
check all that apply
Account Transfer: complete an Account Transfer Form**
**Go to the Scottrade.com Forms Center, or contact us to have the form sent to you.
Under penalties of perjury, I certify that:
1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me).
2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, (b) I have not been notified by the IRS that I am subject to backup withholding
as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. If you are subject to backup
withholding, cross out item 2. The IRS does not require your consent to any provision of this document other than the certification required to avoid backup withholding.
3) I am a U.S. person (including a U.S. resident alien).
By signing this Application, I acknowledge that I have received, read and agree to abide by the terms of the accompanying
Brokerage Account Agreement, which contains a pre-dispute arbitration clause on page 11, item VII-B.
X
Applicant/Authorized Person's Signature
Date
X
Co-Applicant/Authorized Person's Signature
Date
Margin - sign below ONLY if you are applying for margin privileges
*SF1000*
SF1000/12-12
By signing this Application I acknowledge that I have received, read and agree to abide by the terms of the
accompanying Brokerage Account Agreement, including the Margin Accounts provisions starting on page 8.
X
X
Applicant/Authorized Person's Signature
Date
Co-Applicant/Authorized Person's Signature
Date
Page 1 of 2
For SAS Use Only
Registered Principal
*SF2361*
P.O. Box 31759, St. Louis, MO 63131-0759
SF2361/6-11
TRADITIONAL INDIVIDUAL RETIREMENT ACCOUNT
#100 (1/2009)
ACCOUNTHOLDER INFORMATION
DATE
Type of IRA:
Regular
SEP
Transfer
Rollover
NAME
HOME ADDRESS
STATE
CITY
(including a direct
rollover from an employer’s plan)
Recharacterization
BUSINESS PHONE (
ZIP CODE
HOME PHONE (
)
)
DATE OF BIRTH
SOCIAL SECURITY NO.
DESIGNATION OF BENEFICIARY(ies)
The following individual(s) or entity(ies) shall be my primary and/or contingent beneficiary(ies). If neither primary nor contingent is indicated, the individual or entity will
be deemed to be a primary beneficiary. If more than one primary beneficiary is designated and no distribution percentages are indicated, the beneficiaries will be deemed
to own equal share percentages in the IRA. Multiple contingent beneficiaries with no share percentage indicated will also be deemed to share equally.
If any primary or contingent beneficiary dies before I do, his or her interest and the interest of his or her heirs shall terminate completely, and the percentage share of any
remaining beneficiary(ies) shall be increased on a pro rata basis. If no primary beneficiary(ies) survives me, the contingent beneficiary(ies) shall acquire the designated
share of my IRA.
No.
Beneficiary’s Name and Address
Date of Birth
U.S. Social Security
Number (required)
Is this person
a U.S. Citizen?
1.
2.
3.
4.
5.
SPOUSAL CONSENT
I am not married.
Primary or
Contingent
Relationship
Share %
%
Yes
Primary
No
Contingent
Yes
Primary
No
Contingent
Yes
Primary
No
Contingent
Yes
Primary
No
Contingent
Yes
Primary
No
Contingent
%
%
%
%
SIGNATURES
Important: Please read before signing.
I am married.
This section should be reviewed if either the trust or the residence of the
accountholder is located in a community or marital property state and the
accountholder is married. Due to the important tax consequences of giving up one’s
community property interest, individuals signing this section should consult with a
competent tax or legal advisor.
I am the spouse of the above-named accountholder. I acknowledge that I have
received a fair and reasonable disclosure of my spouse’s property and financial
obligations. Due to the important tax consequences of giving up my interest in
this IRA, I have been advised to see a tax professional.
I hereby give the accountholder any interest I have in the funds or property
deposited in this IRA and consent to the beneficiary designation(s) indicated
above. I assume full responsibility for any adverse consequences that may result.
No tax or legal advice was given to me by the Custodian.
I understand the eligibility requirements for the type of IRA deposit I am
making and I state that I do qualify to make the deposit. I have received a copy
of the Application, the 5305-A Plan Agreement, the Financial Disclosure and the
Disclosure Statement. I understand that the terms and conditions which apply
to this IRA are contained in this Application and the Plan Agreement. I agree to
be bound by those terms and conditions. Within seven (7) days from the date I
open this IRA I may revoke it without penalty by mailing or delivering a written
notice to the Custodian.
I assume complete responsibility for:
1. Determining that I am eligible for an IRA each year I make a contribution.
2. Ensuring that all contributions I make are within the limits set forth by the tax laws.
3. The tax consequences of any contribution (including rollover contributions) and
distributions.
I expressly certify that I take complete responsibility for the type of investment
instrument(s) I choose to fund my IRA, and that the Custodian is released of any
liability regarding the performance of any investment choice I make.
X
___________________________________________ _________________
(Accountholder)
(Date)
___________________________________________ _________________
(Authorized Signature of Custodian)
_________________________________________ ___________________
(Signature of Spouse)
(Date)
(Date)
Acceptance by Scottrade, Inc.
___________________________________________
_________________
The Plan shall be deemed to have been accepted by Scottrade, Inc.
upon receipt of all necessary forms, properly completed.
RETURN COPY WITH “SCOTTRADE BROKERAGE ACCOUNT APPLICATION” TO SCOTTRADE, INC.
Page 2 of 2
(Date)
©2009 Ascensus, Inc., Brainerd, MN