[KYLE] 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
Mobile Phone Number*
Other 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*
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 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!

Work Information

Please tell us about your work.
Employment Status*
Employer Name*
Occupation*
Type of Business*
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?
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 find us?*
Google, LinkedIn, Referral, etc
Please specify:
Who referred you?
Should be Empty:

Client Intake Form