New Account Form

International Client Application Form

BROKERAGE ACCOUNT APPLICATION FORM

Account Information

Account Registration

Select the type of registration you want on your Account

Individual

Joint Tenants with Right of Survivorship
If one owner dies, his/her interest passes to the surviving owner(s)

Tenants in Common
If one owner dies, his/her interest passes to his/her estate (50/50, unless otherwise noted)

Other
Contact Heathridge Partners to obtain additional documents that must accompany this application. Certain restrictions may apply.

Account Holder

Mr

Mrs

Ms

Dr
							
 Last name

 First

 Middle

 Email address(es)

 Date of birth (dd/mm/yyyy)

 Home address

 City

 State, Province

 Country

 Postal, Zip Code

 Postal address (if different than above)

 Home phone (if applicable) (Country code-Area code-Number)

 Mobile phone (Country code-Area code-Number)

 Other phone (if applicable) (Country code-Area code-Number)

 Fax (optional) (Country code-Area code-Number)

 Country of citizenship

 Country of residence (if other than above)

Securities industry regulations require that we request the following information:

Employed

Self-Employed

Retired

Unemployed
							
 Employer/Business name

 Nature of business

 Business address

 City

 State, Province

 Country

 Postal, Zip Code

 Business phone (Country code) (City/Area code) (Number)

 Occupation/Position

 Years with employer

Marital Status
									
Single

Married

Divorced
									
 Number of dependents

Additional Account Holder (If applicable)

Mr

Mrs

Ms

Dr
							
 Last name

 First

 Middle

 Email address(es)

 Date of birth (dd/mm/yyyy)

 Home address

 City

 State, Province

 Country

 Postal, Zip Code

 Postal address (if different than above)

 Home phone (if applicable) (Country code-Area code-Number)

 Mobile phone (Country code-Area code-Number)

 Other phone (if applicable) (Country code-Area code-Number)

 Fax (optional) (Country code-Area code-Number)

 Country of citizenship

 Country of residence (if other than above)

Securities industry regulations require that we request the following information:

Employed

Self-Employed

Retired

Unemployed
							
 Employer/Business name

 Nature of business

 Business address

 City

 State, Province

 Country

 Postal, Zip Code

 Business phone (Country code) (City/Area code) (Number)

 Occupation/Position

 Years with employer

Marital Status
									
Single

Married

Divorced
									
 Number of dependents

Is any member of your household a control person (Example: A person who can exercise power or has a controlling interest in a company) in a publicly traded corporation?

Yes
No

If YES, please specify the corporation:

Investment Profile

Account Holder

Investment Knowledge

None
Good
Limited
Extensive

Investment Experience

None

Limited

Good

Excellent

Common Shares

None
Limited
Good
Excellent

Preferred Shares

None
Limited
Good
Excellent

Bonds

None
Limited
Good
Excellent

Money Market

None
Limited
Good
Excellent

New Issues

None
Limited
Good
Excellent

Mutual Funds

None
Limited
Good
Excellent

Options

None
Limited
Good
Excellent

Commodities/Futures

None
Limited
Good
Excellent

Venture Situations

None
Limited
Good
Excellent

Trading Experience (years):

Equities

Bonds

Currencies

Commodities
/Futures

Options

Additional Account Holder

Investment Knowledge

None
Good
Limited
Extensive

Investment Experience

None

Limited

Good

Excellent

Common Shares

None
Limited
Good
Excellent

Preferred Shares

None
Limited
Good
Excellent

Bonds

None
Limited
Good
Excellent

Money Market

None
Limited
Good
Excellent

New Issues

None
Limited
Good
Excellent

Mutual Funds

None
Limited
Good
Excellent

Options

None
Limited
Good
Excellent

Commodities/Futures

None
Limited
Good
Excellent

Venture Situations

None
Limited
Good
Excellent

Trading Experience (years):

Equities

Bonds

Currencies

Commodities
/Futures

Options

Investment Goal

Capital Preservation
Income
Growth
Speculation

Investment Objective Definitions: Capital preservation: The objective of capital preservation is to protect your initial investment by choosing investments that
minimize the potential of any loss of principal. The long-term risk of capital preservation is that the returns may not be adequate to offset inflation. Income: The
primary objective of an income strategy is to provide current income rather than long-term growth of principal. Growth: The objective of a growth strategy is to
increase the value of your investment over time with recognizing a high likelihood of volatility. Speculation: A speculator's objective is to assume a higher risk of loss
in anticipation of potentially higher than average gain by taking advantage of expected price changes

Does anyone other than the account holder(s) have trading authorization over the account?

Yes
No

If yes, please complete and mail Power of Attorney form to add an individual as having trading authority

I /We am/are of legal age to enter in this agreement. I hereby request that Heathridge Partners open an account in the name(s) listed as account holder(s) on this
application. I/We the undersigned agree to provide instructions as an authorized signatory to Heathridge Partners via phone, fax, email or any other method deemed
appropriate by Heathridge Partners without instructions being duly confirmed in writing. Therefore, this signed document allows Heathridge Partners to process
transactions sent via any of the above mentioned mediums without liability in any form to Heathridge Partners or its employees.

I understand there are fees associated with establishing, maintaining, engaging in transactions, and transferring assets out of this account. I further acknowledge that
securities products purchased or sold in a transaction with Heathridge Partners are subject to investment risks, including possible loss of the principal invested. I
understand that Heathridge Partners does not provide tax, legal or accounting advice.

Signature of Primary Account Owner

Signature of Co-Account Owner

ID Document

				FOR Heathridge Partners ONLY
				
 Approved By

 Date Approved (dd/mm/yyyy)

 Print Name of Approver

 Source Code

 Indexing Code

Branch Office and Account Number
					
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