Client Information Form - Keill & Associates
Please fill out as much as you're comfortable with. All information is private and confidential.
Personal Information
Full Legal Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone Type
Home
Cell
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Citizenship (if other than Canadian)
Social Insurance Number
Hometown
How did you hear about us?
Marital Status
Please Select
Single
Married
Common-Law
Divorced
Widowed
Spousal Information
Spouse Full Legal Name
First Name
Last Name
Spouse Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Years Married
Spouse Phone Type
Home
Cell
Spouse Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse Citizenship if other than Canadian
Spouse Email
example@example.com
Spouse SIN
Spouse Hometown
Children
Employment Information (You)
*
Employment Information (Spouse)
Your Family Goals
Short Term Goal - next 3 years
Medium Term Goal - 3 to 10 years
Long Term Goal - longer than 10 years
What Keeps You Up at Night?
Financial Worry
Do you have... (check all that apply)
Do you have... (check all that apply)
A lawyer
A will and Power of Attorney
Life Insurance (not through work)
A Financial Planner
Professional Tax Preparer
Monthly Investment or Savings Plan
Registered Pension Plan at work (you or your spouse)
Last will drafted year
Submit
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