Appendix E PDF – Authentic Asset

1. Account Overview

user

Client Name

Legal Residency (report all)

If other, please specify

Legal Residents of Canada are required to supply their legal province of residence.

If other, please specify

Client Type

Tax Account Type

Account type

Base Currency

If other, please provide Currency

Will all funds in this account belong to the named account holder ONLY and NOT to any third-party individual or entity, in any capacity?

If no, please explain

Will this account be used to invest on behalf of any other person(s) besides the named account holder?

If yes, please explain

Is a third party setting up this account?

If yes, name of third party

2. ACCOUNT HOLDER INFORMATION

Name

Gender

Date of Birth

Marital Status

Spouse Name (if applicable)

Trusted Contact Person

Your Relationship to Trusted Contact

Trusted Contact Phone Number

Do you have any dependents?

Number of Dependents

Please list ages of dependent/s:

Address

Do you have a different mailing address

Address

Primary Phone #

Home

Mobile

Work

Alternative Phone #

3. IDENTIFICATION AND LEGAL STATUS

Please attach copies of 2 identification documents

File

Country of Birth

Do you have a different Country of Citizenship other than Canada?

If yes, please list all other Citizenships

Status in Canada (Please select what is applicable)

If Foreign National, please specify

Are you presently subject to tax in Canada?

Are you a U.S. Permanent Resident (Green Card Holder)?

Are you a Politically Exposed Person?

4. FINANCIALS

Date

Total Assets

Allocation of Assets

Equiity(%)

Bonds(%)

Real Estate(%)

Cash(%)

Other

Net Worth

Liquid Net Worth

Annual Net Income in CAD

Source of Funds

If other, please specify

Does income fluctuate and affect your lifestyle?

In the next 5 years (due to a change in family or business circumstances, inheritance, etc.): Do you expect a large increase in wealth?

If Yes, amount in CAD$

Do you expect a large decrease in wealth?

If Yes, amount in CAD$

Any history of personal bankruptcy or credit issues?

Employment Status

Nature of Business ( by Third Party)

Occupation

Employer Name

Employer Address

Nature of Business (Self-employed)

Occupation

Employer Name

Employer Address

Expected Retirement Date

I confirm that I am an Accredited Investor

5. REGULATORY INFORMATION

Are you: i) a director; ii) a 10% or greater shareholder; or iii) a policy-making officer of any publicly traded company?

If ‘Yes’, please indicate name of controlled corporation or entity:

What is your relationship to the corporation?

If yes, provide the name of the entities

What is your relationship to the partnership or trust?

6. INVESTMENT OBJECTIVES AND RISK TOLERANCE

Investment Objectives

Intend to maintain account

When may draw on assets

Do you have income needs from this account?

If yes, CAD$/mth

Risk Tolerance

What is your willingness to experience volatility to generate higher returns?

Your willingness to risk shorter-term losses for prospect of higher longer-term returns?

Please select the statement that aligns closest to your preference

7. INVESTMENT EXPERIENCE

Stocks

Bonds

Options

Futures

Foreign Exchange

Future Options

Single Stock Futures

8. ACCOUNT RESTRICTIONS AND FUNDING

Are there any regulatory restrictions and/or any particular directions relating to this account?

If yes, please specify

Are you transferring securities in addition to cash from another account?

If yes, amount in CAD$

If Yes, can they be sold by the Firm once they are in the new account?

Please specify any particular directions and regulatory restrictions relating to the account:

9. COMMERCIAL COMMUNICATIONS

The client

Per

Name

Title

Date

Signature

Each party agrees that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.