[NVWM] Prospective Client Profile Form

1
Full Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Contact Numbers
Home Phone
Cell Phone
Work Phone
Fax Number
4
Home Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Communication Preference* This field is required.How would you like us to communicate with you? Check all that apply.
Email
Cell Phone
Home Phone
Work Phone
6
Date of Birth* This field is required.
Date
Month
Day
Year
7
Current Employment Status
Employed
Self-employed/Business Owner
Retired
Other
8
Company InformationIf you are retired, please enter the information for your previous company.
Company Name
Title/Occupation
Please Select
Please Select
Automobiles and Components
Banks
Capital Goods
Commercial and Professional Services
Communication Services
Consumer Durables and Apparel
Consumer Services
Diversified Financials
Energy
Food, Beverage and Tobacco
Food and Staples Retailing
Health Care Equipment and Services
Household and Personal Products
Insurance
Materials
Media
Pharmaceuticals, Biotech and Life Sciences
Real Estate
Retailing
Semiconductors and Semiconductor Equipment
Software and Services
Technology Hardware and Equipment
Transportation
Utilities
Industry
9
Primary Source(s) of IncomePlease select at least one option or add your own if none of these apply.
Personal Income
Spouse/Former Spouse
Other Family Member
Trust/Inheritance
Investments
Retirement Funds
Other
10
Do you have a spouse or significant other you would like to include?* This field is required.
YESNO
11
Significant Other's Full Name
First Name
Last Name
12
Significant Other's Email
example@example.com
13
Significant Other's Phone Information
Home Phone
Cell Phone
Work Phone
Fax Number
14
Significant Other's Date of Birth* This field is required.
Date
Month
Day
Year
15
Significant Other's Employment Status
Employed
Self-employed/Business Owner
Retired
Other
16
Significant Other's Company InformationIf you are retired, please enter the information for your previous company.
Company Name
Title/Occupation
Please Select
Please Select
Automobiles and Components
Banks
Capital Goods
Commercial and Professional Services
Communication Services
Consumer Durables and Apparel
Consumer Services
Diversified Financials
Energy
Food, Beverage and Tobacco
Food and Staples Retailing
Health Care Equipment and Services
Household and Personal Products
Insurance
Materials
Media
Pharmaceuticals, Biotech and Life Sciences
Real Estate
Retailing
Semiconductors and Semiconductor Equipment
Software and Services
Technology Hardware and Equipment
Transportation
Utilities
Industry
17
Significant Other's Primary Source(s) of IncomePlease select at least one option or add your own if none of these apply.
Personal Income
Spouse/Former Spouse
Other Family Member
Trust/Inheritance
Investments
Retirement Funds
Other
18
Wedding Date(if applicable)
Date
Year
Month
Day
19
What financial goals do you want to achieve?IDEAS TO GET YOU STARTED EDUCATION: Send your children or grandchildren to college INHERITANCE: Leave a stress-free, tax-efficient inheritance to your family FUN: Travel around the world, buy a vacation home CHARITY: Start a family foundation RETIRE: Have enough money to last until age 100
Short-term (in the next 12 months)
Mid-term (in the next 5 years)
Long-term (in retirement)
Legacy (for your heirs)
20
Your Existing Financial PlansGive us a quick idea of the plans you already have in place.
Please Select
Please Select
I have a financial plan, and it has been updated in the last year.
I have a financial plan, but it has not been updated in several years.
I do not have a financial plan.
I’m not sure if I have a financial plan.
Financial Plan
Please Select
Please Select
I have an estate plan, will, or trust, and it has been updated in the last year.
I have an estate plan, will, or trust, but it has not been updated in years.
I do not have an estate plan, will, or trust.
I’m not sure if I have an estate plan, will, or trust.
Estate Planning
Please Select
Please Select
I have a retirement plan, and it has been updated in the last year.
I have a retirement plan, but it has not been updated in several years.
I do not have a retirement plan.
I’m not sure if I have a retirement plan.
Retirement Plan
Please Select
Please Select
I have a tax-minimization plan, and it has been updated in the last year.
I have a tax-minimization plan, but it has not been updated in years.
I do not have a tax-minimization plan.
I’m not sure if I have a tax-minimization plan.
Tax Plan
Please Select
Please Select
I have life and health insurance, and it has been updated in the last year.
I have life and health insurance, but it has not been updated in years.
I do not have life and/or health insurance.
I’m not sure if I have life and/or health insurance.
Insurance
21
What services are you looking for in the next 12 months?Check all that apply.
Business Owners
Estate Planning
Education
Insurance
Investment Management
Retirement Planning
Tax Planning
Other
22
Business OwnersWhat solutions are you looking for in the next 12 months? Check all that apply.
I plan to buy, sell, or start a business.
I need key-person insurance.
I need group insurance for employees.
Other
23
Estate PlanningWhat solutions are you looking for in the next 12 months? Check all that apply.
I need an estate plan or need to revise my existing one.
I recently changed, or wish to change, my policy beneficiary.
Other
24
EducationWhat solutions are you looking for in the next 12 months? Check all that apply.
I want to save for my children’s/grandchildren’s college education.
Other
25
InsuranceWhat solutions are you looking for in the next 12 months? Check all that apply.
I need life insurance protection for my family or business.
My spouse needs insurance.
I want to improve my children’s/grandchildren’s life insurance, including guaranteeing their future insurability.
I want to learn more about disability income insurance.
I want long-term care insurance.
I need health insurance.
Other
26
Investment ManagementWhat solutions are you looking for in the next 12 months? Check all that apply.
I need comprehensive management of my assets.
I want my investments reviewed for risk- and tax-reduction opportunities.
I want to learn more about asset-allocation strategies.
Other
27
Retirement PlanningWhat solutions are you looking for in the next 12 months? Check all that apply.
I have decided to retire or have been thinking about retiring.
I need additional retirement income.
I need a retirement plan.
Other
28
Tax PlanningWhat solutions are you looking for in the next 12 months? Check all that apply.
I want to reduce my taxes and need a comprehensive tax plan.
Other
29
What qualities are most important for you in a financial advisor?Please rate how important on a scale of 1-10, where 0 = not important at all and 10 = absolutely critical.
30
Would you like to learn more about effectively managing your wealth, either through educational workshops or by subscribing to our wealth management newsletters?
YESNO
31
Please feel welcome to share any additional information that may help us make your financial plan and investments all-inclusive or any further questions you’d like to discuss.
Huge
Large
Normal
Small
Ok
Ok
32
How did you find us?
Friend or colleague
Attorney or tax advisor
Internet search
Yellow Pages
Family member
Other advisor
Mailing
Other
33
Who may we thank for referring you?
Referrer's Name
Company Name (if applicable)
Referrer's Email
34
I confirm that the information given in this form is true, complete and accurate.* This field is required.
Yes, to my knowledge, all the information given in this form is accurate.
Should be Empty: