Register – Benjamin Securities Account Management

Personal Information

Name:*

First Last

Country of Citizenship:*

I am a Legal Resident of:*

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 Country

The above address is:*

Home

Business

Marital Status:*

Married

Single

Email:*

Primary Phone:*

Hidden

Business Phone:*

Hidden

Mobile Phone:*

Employment Information

Your 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

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

Firm and Position within Public Company:*

Your Finances

Annual Income:*

Hidden

Liabilities:*

Net Worth (excluding residence):*

Liquid Net Worth:*

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:*

15%

28%

31%

38% and higher

Unknown

Investment Experience

Please 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 Information

Account Time Horizon:*

<1 Year

1-3 Years

4-6 Years

7-8 Years

9-11 Years

12+ Years

Liquidity Needs:*

Other Investments:*

Real Estate

Tax Shelter

Savings

Stocks

Bonds

Options

Not Applicable

Total Value of Other Investments:*

Do you rely on these funds for retirement?*

Yes

Additional Disclosures

Are you or any member of your immediate family a political figure or were a political figure within the last 12 months?*

Yes

Identity Confirmation

What type of identification do you have?*

U.S. Driver's License / State ID

Passport / Residency ID

Hidden

Issuing Entity for Identification*

Country / State Issuing the ID being used

Upload 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 citizenship

Please 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):

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Comments

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Enrollment Questionnaire

Personal Information

Employment Information

Your Finances

Investment Experience

Additional Account Management Information

Additional Disclosures

Identity Confirmation