Plesase provide us with the following information and check the boxes that apply to you. An investment advisor will contact you soon.

Name: Pacific National Bank Acct. No.:
City/Country: E-Mail:
Phone: Country
Residency:
1. The majority of investors define risk as some possibility of losing money through an investment. In general, the greater the risk, the greater the return potential of an investment. By using this definition, which of the following investment objectivesappeal to you the most?
Asset Protection: I am willing to settle for small or modest invetment returns, while assuming a low risk profile of losing money.
Income: I am interested in current income on my investment. I am ready to accept the fact that my investment's value may fluctuate with a possibility of money loss. My capital's growth is only of relative importance to me.
Growth and Income: What I want is both capital's growth and current income. I am ware that subject to market conditions, there can be a gain or a loss.
Growth: I am more concerned with a long term capital growth. I can tolerate certain fluctuations in the market cycle, with negative returns knowing that I am pursuing higher returns compared to less risky investments.  
2. Which option best describes your knowledge on investments?
I don't know what is going on in the stock and bond market.
I have a basic knowledge on the stock and bond market.
I am knowledgeable of the stock and bond market.
I am an experienced investor in stocks and bonds.
3. Is it difficult for you to save money on a regular basis?
Yes
No
4. Do you depend on earnings generated by savings and investments to cover your budget?
Yes
No
5. Which of the following best describes your time-frame to reach your investment goals?
Very long term: 10 years or more
Long term: 5 to 10 years
Intermediate goal: 3 to 5 years
Short term: less than 3 years
6. In case of death, disability or other emergency, do you have enough insurance or quickly available monies to cover your budget expenses for at least one year?
Yes
No
7. How do you expect youre family's income to behave in the next five to seven years?
Lower income
Higher income
Same income
8. Which of these best fit your family's income level in US dollars? (Please include salary, interest and dividend returns, social security, business profits and other income)
Under $25,000
$25,000 - $50,000
$50,000 - $100,000
Over $100,000
9. Please check household annual income that best accounts for your net assets in US dollars.
Under $25,000
$25,000 - $100,000
$100,000 - $500,000
$500,000 - $1,000,000
Over $1,000,000
10. Is there a specific type of investment that you are particularly interested in?

Investment Products offered by Pacific National Bank: (i) are not deposits insured by the FDIC; (ii) are not obligations of Pacific National Bank; (iii) are not guaranteed by Pacific National Bank; (iv) involve investment risks, including the possible loss of principal.