Benjamin Securities Account Management Portal Enrollment Questionnaire "*" indicates required fields Step 1 of 7 14% PhoneThis field is for validation purposes and should be left unchanged.Personal InformationName:* First Last Country of Citizenship:*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land IslandsI am a Legal Resident of:*AustraliaAustriaBelgiumCanadaChileCzechiaDenmarkFinlandFranceGermanyHong KongHungaryIrelandIsraelItalyJapanJerseyLuxembourgNetherlandsNew ZealandNorwayPolandPortugalSingaporeSpainSwedenSwitzerlandTaiwanUnited KingdomUnited StatesNone of These Date of Birth:* MM slash DD slash YYYY Either a U.S. Social Security Number or a Foreign Tax Identification Number is required.U.S. SSN / ITIN:*Foreign Tax Number:*Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country The above address is:* Home Business Marital Status:* Married Single Email:* Primary Phone:*This field is hidden when viewing the formBusiness Phone:*This field is hidden when viewing the formMobile Phone:* Employment InformationYour Employment Status:* Employed Self-Employed Not Employed Employer Name:*Position:*Source of Income:*Are you or an immediate family member affiliated with or employed by another Broker/Dealer member firm?* Yes No Name of and position in Broker/Dealer firm:*Are you or an immediate family member an executive officer or holder of 10% or more of a publicly traded company?* Yes No Firm and Position within Public Company:* Your FinancesAnnual Income:*$0-$50,000$50,000-$99,999$100,000-$199,999$200,000-$299,999$300,000-$399,999$400,000-$499,999$500,000-$749,999$750,000-$999,999$1,000,000+This field is hidden when viewing the formLiabilities:*$0-$50,000$50,000-$99,999$100,000-$199,999$200,000-$299,999$300,000-$399,999$400,000-$499,999$500,000-$749,999$750,000-$999,999$1,000,000+Net Worth (excluding residence):*Less than $100,000$100,000-$249,999$250,000-$499,999$500,000-$999,999$1,000,000-$2,999,999$3,000,000+Liquid Net Worth:*Less than $100,000$100,000-$249,999$250,000-$499,999$500,000-$999,999$1,000,000-$2,999,999$3,000,000+ Investment Objectives:* Preservation of Principal/Income Balanced Growth Growth Aggressive Growth/Aggressive Income Speculation Risk Exposure:* Minimal Low Moderate Aggressive Speculative Based on your investment objective and/or risk tolerance, you are not eligible for the Capital Markets Participation Program. The Capital Markets Participation Program is best suited for investors with an investment objective of growth, aggressive growth, or speculation, and risk tolerance of moderate, aggressive, or speculative.Tax Bracket:* 0% 15% 28% 31% 38% and higher Unknown Investment ExperiencePlease check the products/strategies that best reflect your investment experience to date.Investment Experience - Stocks Stocks Years Experience with Stocks:*Investment Experience - Bonds Bonds Years Experience with Bonds:*Investment Experience - Mutual Funds Mutual Funds Years Experience with Mutual Funds:*Investment Experience - Exchange Traded Funds Exchange Traded Funds Years Experience with Exchange Traded Funds:*Investment Experience -Options Options Years Experience with Options:*Investment Experience - Margin Margin Years Experience with Margin:*Investment Experience - Futures Futures Years Experience with Futures:*Investment Experience - Annuities Annuities Years Experience with Annuities:*Investment Experience - Active Short-Term Trading Active Short-Term Trading Years Experience with Active Short-term Trading:*Investment Experience - Inverse / Leveraged Products Inverse / Leveraged Products Years Experience with Inverse / Leveraged Products:*Investment Experience - Alternative Investments Alternative Investments Years Experience with Alternative Investments:*Investment Experience - None* None Additional Account Management InformationAccount Time Horizon:* <1 Year 1-3 Years 4-6 Years 7-8 Years 9-11 Years 12+ Years Liquidity Needs:*Less than $1,000$1,000 - $9,999$10,000 - $49,999$50,000 - $99,999$100,000 - $249,999$250,000+Other Investments:* Real Estate Tax Shelter Savings Stocks Bonds Options Not Applicable Total Value of Other Investments:*$0-$100,000$100,000-$200,000$200,000-$500,000$500,000-$1,000,000$1,000,000+Not ApplicableDo you rely on these funds for retirement?* Yes No Additional DisclosuresAre you or any member of your immediate family a political figure or were a political figure within the last 12 months?* Yes No Identity ConfirmationWhat type of identification do you have?* U.S. Driver's License / State ID Passport / Residency ID This field is hidden when viewing the formIssuing Entity for Identification*Country / State Issuing the ID being usedUpload the front side of your Driver's License or State-issued ID:*Accepted file types: jpg, jpeg, png, pdf, Max. file size: 100 MB. Upload the back side of your Driver's License or State-issued ID:*Accepted file types: jpg, jpeg, png, pdf, Max. file size: 100 MB. Please scan or photograph the first page of your passport as proof of citizenshipPlease scan or photograph a Government-Issued ID of Resident Jurisdiction.Upload a clear picture of your ID:*Accepted file types: jpg, jpeg, png, pdf, Max. file size: 100 MB. Invitation Code (Optional):Please note: You may encounter a wait of up to 30 seconds before receiving confirmation. Please do not refresh this page while it is processing. Δ
