Encrypted Client Intake Form
Please tell us a little bit about yourself. This form is encrypted for your security. We never share this information and only use it to complete forms you authorize. We use this information to create your "Gemini, Private Client Performance Portal and Vault". We use this data to complete brokerage applications and other financial accounts that you may authorize. We deposit our SEC required "Regulatory Documents" into that Vault prior to our in-person meeting. This data is needed to create that portal.
By typing my name below I give permission to share my email address to Lighthouse Retirement, for the exclusive purpose of attaching to our Constant Contact Client Communication System as well as other account documentation and for the purpose of creating my Gemini Private Client Performance Portal and Vault. We never sell or share any client data.
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Type name here.
As my gift for just coming to a meeting, I'd like...
Lighthouse Retirement "Golden Reserved for our Next Great Client" Coffee Mug
Lighthouse Retirement Crystal Engraved Whiskey Glass
Lighthouse Retirement Crystal Engraved Red Wine Goblet
Lighthouse Retirement Crystal Engraved "Nick and Nora" Teeny Tiny Martini Glass
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone
*
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
example@example.com
Date of Birth
*
Client Social Security
Client Drivers License Number, Issue, Expiration, State.
Please send a copy by eMail or Scan.
Are You Employed or Retired
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Position or Title
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Employer Name, Address.
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Are You Single, Married, Widowed or Divorced
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Spouses Name-In Most States, the Spouse is Mandated to be the Primary Beneficiary Unless Otherwise, Disclaimed in Writing.
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First Name
Last Name
Spouses Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouses Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Spouses Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spouses EMail
*
example@example.com
Date of Birth
*
Spouse Social Security
Spouse Drivers License Number, Issue, Expiration, State
Please send a copy by eMail or Scan.
Are You Employed or Retired
*
Position or Title
*
Employer Name, Address
*
Contingent Beneficiaries
*
Rows
Full Name
Mailing Address
Email Addresses
DOB
SSN
Phone Number
Percentage.
Must Equal 100%
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2
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Please tell us about your expectations for your account. What is the minimum acceptable, annual return, you require to continue your relationship with our firm, for years to come?
Please tell us about all of the sources of income, you and your spouse have available for retirement including pensions, retirement accounts, annuities and other savings accounts. Be detailed please.
Please tell us about the Assets available for Investing such as where the money is coming from and the amounts. It's OK to approximate.
Please tell us about your expectations. For example, how long before you need to access these funds? How much income per year will you need from this account starting immediately, if any? In the next 5 years? What type of return on your investments, would make you so happy, that you would continue our relationship for many years?
Submit
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