Personal Needs Assessment Form

First Name: Last Name:

Street Address:

City: Province: AB BC MB NB NF NS ON PE PQ SK Postal Code:

Home Phone: Work Phone: E-Mail:

Age Group: Under 25 years old 26 to 30 years old 31 to 35 years old 36 to 40 years old 41 to 45 years old 46 to 50 years old 51 to 55 years old Over 56 years of age

What is your approximate net worth?
Less than $25,000
Between $25,000 and $50,000
Between $50,001 and $100,000
Between $100,001 and $250,000
Greater than $250,000

What are your financial goals?
Retirement
Savings (home, childrens education etc.)
Tax Shelter

How long do you plan to hold these investments?
Less than 2 years.
Between 2 and 5 years.
More than five years and less than 10 years.
Between 10 and 20 years.
More than 20 years.

How important is it that you have access to your investment capital in case of emergencies or other investment opportunities?
It is extremely important.
It is important.
It is slightly important.
It is not important at all.

How important is it that you receive an income from your investments?
It is extremely important.
It is important.
It is slightly important.
It is not important at all.

How would you describe your reaction to financial news that may have a detrimental effect on your investments?
I would be very anxious and likely sell my investments.
I would be fearful and consider selling my investments.
I would be uncomfortable but would hold my investments.
I would remain calm and definitely hold my investments.

Which performance numbers most concern you?
Monthly performance numbers.
Quarterly performance numbers
Annual performance numbers.

Within the past five years, how often have you invested money in speculative investments?
I have never invested speculatively.
I have invested speculatively once.
I have invested speculatively twice.
I have invested speculatively three or more times.

Would you like specific information relevant to your needs mailed to you?
Yes
No

Do you have any comments or additional questions?

All information provided is kept in confidence. No one will contact you unless you specifically request information.

Thank you.