Application Form – JEK Japan

BROKERAGE ACCOUNT APPLICATION FORM

Account Information

Account Registration

Select the type of registration you want on your Account

Individual

Joint Tenants with Right of Survivorship

If one owner dies, his/her interest passes to the surviving owner(s)

Tenants in Common

If one owner dies, his/her interest passes to his/her estate (50/50, unless otherwise noted)

Other

Contact Jek Japan to obtain additional documents that must accompany this application. Certain restrictions may apply.

Account Holder

                            Mr
                            Mrs
                            Ms
                            Dr
                        
                                     Last name

                                     First

                                     Middle

                                     Email address(es)

                                     Date of birth (mm/dd/yyyy)

                                     Home address

                                     City

                                     State, Province

                                     Country

                                     Postal, Zip Code

                                     Postal address (if different than above)

                                     Home phone (if applicable) (Country code-Area code-Number)

                                     Mobile phone (Country code-Area code-Number)

                                     Other phone (if applicable) (Country code-Area code-Number)

                                     Fax (optional) (Country code-Area code-Number)

                                     Country of citizenship

                                     Country of residence (if other than above)

Securities industry regulations require that we request the following information:

                            Employed
                            Self-Employed
                            Retired
                            Unemployed
                        
                                     Employer/Business name

                                     Nature of business

                                    Business address

                                     City

                                     State, Province

                                     Country

                                     Postal, Zip Code

                                     Business phone (Country code) (City/Area code) (Number)

                                     Occupation/Position

                                     Years with employer

Marital Status
SingleMarriedDivorced

                                     Number of dependents

Additional Account Holder (If applicable)

                            Mr
                            Mrs
                            Ms
                            Dr
                        
                                     Last name

                                     First

                                     Middle

                                     Email address(es)

                                     Date of birth (mm/dd/yyyy)

                                     Home address

                                     City

                                     State, Province

                                     Country

                                     Postal, Zip Code

                                     Postal address (if different than above)

                                     Home phone (if applicable) (Country code-Area code-Number)

                                     Mobile phone (Country code-Area code-Number)

                                     Other phone (if applicable) (Country code-Area code-Number)

                                     Fax (optional) (Country code-Area code-Number)

                                     Country of citizenship

                                     Country of residence (if other than above)

Securities industry regulations require that we request the following information:

                            Employed
                            Self-Employed
                            Retired
                            Unemployed
                        
                                     Employer/Business name

                                     Nature of business

                                         Business address

                                     City

                                     State, Province

                                     Country

                                     Postal, Zip Code

                                     Business phone (Country code) (City/Area code) (Number)

                                     Occupation/Position

                                     Years with employer

Marital Status
SingleMarriedDivorced

                                     Number of dependents

Is any member of your household a control person (Example: A person who can exercise power or has a controlling interest in a company) in a publicly traded corporation?

Yes No

If YES, please specify the corporation:

Investment Profile

Account Holder

Investment Knowledge

None Good Limited Extensive

Investment Experience

None

Limited

Good

Excellent

Common Shares

None Limited Good Excellent

Preferred Shares

None Limited Good Excellent

Bonds

None Limited Good Excellent

Money Market

None Limited Good Excellent

New Issues

None Limited Good Excellent

Mutual Funds

None Limited Good Excellent

Options

None Limited Good Excellent

Commodities/Futures

None Limited Good Excellent

Venture Situations

None Limited Good Excellent

Trading Experience (years):

Equities

Bonds

Currencies

Commodities /Futures

Derivatives

Additional Account Holder

Investment Knowledge

None Good Limited Extensive

Investment Experience

None

Limited

Good

Excellent

Common Shares

None Limited Good Excellent

Preferred Shares

None Limited Good Excellent

Bonds

None Limited Good Excellent

Money Market

None Limited Good Excellent

New Issues

None Limited Good Excellent

Mutual Funds

None Limited Good Excellent

Options

None Limited Good Excellent

Commodities/Futures

None Limited Good Excellent

Venture Situations

None Limited Good Excellent

Trading Experience (years):

Equities

Bonds

Currencies

Commodities /Futures

Derivatives

Investment Goal

Capital Income Growth Speculation

Investment Objective Definitions: Capital preservation: The objective of capital preservation is to protect your initial investment by choosing investments that minimize the potential of any loss of principal. The long-term risk of capital preservation is that the returns may not be adequate to offset inflation. Income: The primary objective of an income strategy is to provide current income rather than long-term growth of principal. Growth: The objective of a growth strategy is to increase the value of your investment over time with recognizing a high likelihood of volatility. Speculation: A speculator's objective is to assume a higher risk of loss in anticipation of potentially higher than average gain by taking advantage of expected price changes

Does anyone other than the account holder(s) have trading authorization over the account?

Yes No

If yes, please complete and mail Power of Attorney form to add an individual as having trading authority

I /We am/are of legal age to enter in this agreement. I hereby request that Jek Japan open an account in the name(s) listed as account holder(s) on this application. I/We the undersigned agree to provide instructions as an authorized signatory to Jek Japan via phone, fax, email or any other method deemed appropriate by Jek Japan without instructions being duly confirmed in writing. Therefore, this signed document allows Jek Japan to process transactions sent via any of the above mentioned mediums without liability in any form to Jek Japan or its employees.

I understand there are fees associated with establishing, maintaining, engaging in transactions, and transferring assets out of this account. I further acknowledge that securities products purchased or sold in a transaction with Jek Japan are subject to investment risks, including possible loss of the principal invested. I understand that Jek Japan does not provide tax, legal or accounting advice.

Signature of Primary Account Owner

Signature of Co-Account Owner

                FOR Jek Japan ONLY
            
                             Approved By

                             Date Approved (mm/dd/yyyy)

                             Print Name of Approver

                         Source Code

                         Indexing Code

Branch Office and Account Number