New Client Intake Form (new account opening)

Client Intake Form

Hello! This form is for new clients who wish to open an account at Base Wealth Management.
Let's start with the basics...
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Have you ever used a different name? (Please list.)
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from home address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Mobile Phone Number
Work Phone Number
Email
example@example.com

More about you

Now let's get a little more detailed...
Birthdate

MonthDayYear
Date
Social Security Number
Marital Status
Number of Dependents
State of Birth
Country of Citizenship
Country of Birth
Do you have any other Citizenships?
Please list.
Drivers License Number
Drivers License State
Drivers License Issue Date

MonthDayYear
Date
Drivers License Expiration Date

MonthDayYear
Date
Attach a picture or scan of your drivers license.

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If you are on your phone or tablet, you can take a photo of your Drivers License here!
Attach a picture or scan of your passport.

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If you are on your phone or tablet, you can take a photo of your Passport here!

Investment Experience

Please let us know about your investment experience.
How would you rate your Risk Tolerance for Investing?

Conservative - Protecting my principal is more important than growth.Conservative / Moderate - Low Risk with a little growth. Middle of the road.Moderate - Balance of protection and growth.Moderate / Aggressive - More Risk than protection, designed for growth.Aggressive - All growth for max returns with possibility of large fluctuation in value.Other
Years of experience investing in Mutual Funds?
Years of experience investing in Stocks / ETF's?
Years of experience investing in Bonds?
Years of experience investing in Annuities?
Years of experience investing in Options / Futures / Margin / Hedge Funds?

Work Information

Please tell us about your work.
Employment Status
Employer Name
Occupation
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you been with your current employer?
Annual Income (Just you)
Household Income
Household Net Worth
Are you or anyone in your immediate family employed by the securities industry?
Are you or any one of your immediate family members an officer, director or 10% (or more) shareholder in a publicly traded company?

Beneficiaries

Let's list your beneficiaries...
First, what is your mother's maiden name?
Beneficiary 1 (Primary)

First NameMiddle NameLast NameSuffix
Beneficiary 1 Relationship to You?
Beneficiary 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beneficiary 1 Email
example@example.com
Beneficiary 1 Phone Number
Beneficiary 1 Social Security
Beneficiary 1 Birthdate

MonthDayYear
Date
Would you like to add another beneficiary?
Beneficiary 2

First NameMiddle NameLast NameSuffix
Beneficiary 2 Relationship to You?
*A contingent beneficiary is a beneficiary of proceeds or a payout if the primary beneficiary is deceased or unable to be located.
Is this a Primary or Contingent Beneficiary?

PrimaryContingent
What percentage would you like to go to this Beneficiary?
Beneficiary 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beneficiary 2 Email
example@example.com
Beneficiary 2 Phone Number
Beneficiary 2 Social Security
Beneficiary 2 Birthdate

MonthDayYear
Date
Would you like to add another beneficiary?
Beneficiary 3 info (if you have a third beneficiary or contingent beneficiary)
Would you like to add another beneficiary?
Beneficiary 4 info (or contingent beneficiary info)

Anything else?

This is the home stretch!
Questions or Comments?
If you want to link your accounts to your checking account or do a monthly bank draft for you investments, please attach a picture of a voided check for the account you would like to link. This is a free service.

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If you are on your phone or tablet, you can take a photo here of the voided check!
Attach your most recent statement(s), including bank, 401(k), life insurances, mortgage & other investments. (If we are transferring an account or working on a financial plan).

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How did you hear about us?*
Who referred you?
Please Specify:
Should be Empty:

Client Intake Form