THIRD-PARTY INVESTMENT
MANAGEMENT PROGRAM
Account #
Advisor Code
Case #
Funding Account #

For detailed instructions, see pages 23 through 24.

INVESTMENT ADVISOR: TO BE COMPLETED BY ADVISOR
Investment Advisor Firm and Primary Contact
Firm Name:
Smockey
Primary Contact:
1
ACCOUNT OWNER: COMPLETE ALL INFORMATION BELOW FOR THE PRIMARY OR MINOR ACCOUNT OWNER, TRUSTEE OR PARTICIPANT
First Name:
Middle Initial:
Last Name:
Social Security Number:
Date of Birth:
Primary Telephone Number:
Secondary Telephone Number
Email Address (required for electronic delivery of your account statement and trade confirmations):
Home Street Address (No PO Boxes):
City:
State:
Zip Code:
Mailing Address (If different from above):
City:
State:
Zip Code:
Title in Organization (if this is an entity account):
Please specify if you are:
 Employed  Self-employed  Unemployed  Retired  Homemaker  Student
Source of income (if Unemployed, Retired, Homemaker, or Student):
Employer Name (If self-employed, please provide the name of your business and industry):
Occupation:
Type of Business:
Employer Street Address:
City:
State:
Zip Code:
Check here if you are a:
 U.S. Citizen  Permanent Resident  Not a U.S. Citizen
If a Permanent Resident, please attach a copy of an unexpired Permanent Resident card.
Country of Citizenship (For non-U.S. Citizens and Permanent Residents):
Country of Dual or Secondary Citizenship (if applicable):
Country of Birth (For non-U.S. Citizens and Permanent Residents):
Non-U.S. citizens: Do you hold a current U.S. immigration visa?  Yes  No Specify visa type: Test Visa Value Visa Number: 1234567-1234567-1234567 Expiration: ___________ (Nonresident aliens must submit Form W-8BEN and a copy of a current passport. If a U.S. address is listed, then attach a signed Form TDAI 835 "Letter of Explanation of U.S. Mailing Address/U.S Phone Number Attachment to Form W-8".)
 Check here if you, your spouse, any member of your immediate family, including parents, in-laws, siblings, and dependents, and any personal or business associate is a senior political figure (SPF). Specify the name of the SPF, political title, and relationship to the Account Owner, and country of office:
 Check here if you, your spouse, any member of your immediate family, including parents, in-laws, siblings, and dependents is a director, 10% shareholder, or policy-making officer of a publicly traded company. Specify the company name, address, city, and state:
 Check here if you, your spouse, any member of your immediate family, including parents, in-laws, siblings, and dependents is licensed, employed by, or associated with, a broker-dealer firm, a financial services regulator, securities exchange, or member of a securities exchange. If checked, please specify entity below, and provide a copy of the required authorization letter with this application:
TDAI 4954 REV. 11/15
2
CO-OWNER/TRUSTEE/CUSTODIAN: COMPLETE ALL INFORMATION BELOW FOR THE CO-OWNER/TRUSTEE/CUSTODIAN
First Name:
Middle Initial:
Last Name:
Social Security Number:
Date of Birth:
Primary Telephone Number:
Secondary Telephone Number
TDAI 4954 REV. 11/15