Equity Only Trading Account Application Form for Pension Clients

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1 Equity Only Trading Account Application Fm f Pension Clients Part 1 - Bene icial Owner Infmation Mr. Mrs. Ms. Other (please specify) First Name: Date of Birth: PPS Number: Home Address: Surname: Place of Birth: Address: Time at Current Address: Previous Address (less than three years): Occupa on: Wk Phone: Home Phone: Mobile Phone: Part 2 - Trustee/QFM Infmation Scheme Name: ; Name of Trustee / QFM: Address: Date of Incpa on: Tax Number: Part 3 - Pension Bank Account Details Note: These details are required so we can transfer monies to you electronically from your accounts. Please note we cannot transfer monies to third party accounts. Account Name: Name of Bank/Building Society: Address of Bank/Building Society: IBAN No: Swi /BIC:

2 Part 4 - Investment Infmation Investment Objectives What are your investment objec ves? (please ck appropriate) Investment Growth Specula on Hedging Addi onal Income Balanced Income & Investment Growth Investment Experience How would you describe your investment knowledge and experience: Limited Good Extensive Which of the below investment instruments do you have experience knowledge of: Stocks Bonds/Fixed Income CFDs Structured Products and Tracker Bonds Property/Mezzanine Finance Feign Exchange Funds and Collec ve Investments Futures, Swaps, Op ons Other Deriva ves Attitude to Risk and Expected Returns Please indicate below your general a tude towards investment risk and return on a scale of 1 to 10, where 1 would indicate that you may have the most conserva ve expecta ons in terms of risk taking and expected returns, and 10 would indicate that you may have higher expecta ons of risk taking f greater returns Please note that f Advisy and Discre onary clients we may ask addi onal ques ons around investment risk pri to providing services. Recent trading experience (if applicable) Have you made an average frequency of 10 trades per quarter over the last four quarters? Yes No What is the average size of transac on: In what capacity have you dealt: Execu on-only Advisy Managed/Discre onary Have you wked in the financial sect f at least one year in a professional posi on which requires knowledge of the transac ons you will expect to be provided by Conexim. If so, please detail here: Do you understand the nature and risks of margined ( leveraged) transac ons? Yes No Part 5 - Financial Details Does your financial instrument p olio, including cash deposits and financial instruments exceed 500,000? Yes No Please indicate the approximate value of your investment holdings below: Cash Deposits Bonds/Trusts Traded Shares Collec ve Investment Funds Other Investments (notes, funds etc) Property (excluding home) Total Browings (excluding home) Please indicate your annual sources of income: Employment Pension (if re red) Rental Income Other Please indicate the sources of wealth/funds in rela on to this investment: Part 6 - Investment Objectives and Restrictions In your own wds, please outline your investment objec ves and also please indicate if you have any specific investment restric ons. Please note that f Advisy and Discre onary clients we may ask addi onal ques ons around your specific investment objec ves and restric ons pri to providing services.

3 Part 7 - Bene icial Owner Declarations 7.1. Declara on I declare that the infma on provided by me in this Applica on Fm and in this Declara on is crect and I undertake to infm Wealth Op ons without delay and in wri ng should any of the infma on change Receipt and Understanding of Terms of Business I have received the Terms rela ng to the Wealth Op ons Broker Pla m, and have read them carefully. I understand that Wealth Op ons Ltd ( Wealth Op ons ), Conexim Adviss Ltd. ("Conexim"), Pershing Securi es Interna onal Limited ( PSIL ) and I are bound by the Terms if my applica on is accepted. I further note that the Terms may subsequently change as set out in the Terms Receipt and Consent of Order Execu on Policy I have received infma on regarding both Conexim and PSL s Order Execu on Policy, and by signing this document I consent to having my ders executed as set out in those policies Express Consent to Execu on of an Order outside of a Regulated Market MTF Where I have requested Conexim to transmit an der f execu on in an instrument admi ed to trading on a Regulated market ( RM ) Mul lateral Trading Facility ( MTF ), then I acknowledge that Pershing Securi es Ltd ("PSL") may execute such der outside an RM MTF in accdance with PSIL s Execu on Policy and I hereby give our express consent f such execu on Receipt and understanding of Summary Conflicts of Interest Policy I have received and understand the enclosed summary Conflicts of Interest Policies from Wealth Op ons, Conexim and PSIL Fees, Commissions and Charges I have received details of the fees, commissions and charges in rela on to investment in the Wealth Op ons Broker Pla m and I have agreed to these. I confirm that Conexim has explicit permission to deduct such amounts from your account(s) to sa sfy any indebtedness to Wealth Op ons, Conexim PSIL Taxa on I acknowledge and confirm I understand that there can be no guarantee that the tax treatment any tax advantage promoted as part of any investment scheme will remain in existence. I acknowledge and confirm that Wealth Op ons Conexim will not be responsible f assessing the personal tax implica ons of inves ng in any par cular instrument. I will always take independent professional tax advice befe making an investment decision. Conexim will never act as a promoter tax adviser in rela on to transac ons schemes designed to enable a person to obtain a tax advantage, as defined in the Finance Act Should I knowingly receive a tax advantage from any par cular investment series of investments, I hereby confirm and acknowledge that it is I, my tax advis, the promoter of any such scheme who is responsible f disclosing any such tax advantage gained under the mandaty disclosure regime introduced by the Finance Act 2010, any applicable regime in place at any par cular me, and it is not the responsibility of Wealth Op ons Conexim to iden fy disclose any tax advantage gained from any such transac ons W-8 BEN I have received a copy of the W-8 BEN fm and a document designed to assist in its comple on. I will be unable to trade in US Securi es un l a crectly completed W-8 BEN has been provided to Wealth Op ons / Conexim and this has been lodged with the appointed withholding agent. It is beneficial f clients who may be selling US securi es and possibly receiving income in the fm of dividends from US securi es to complete this fm, as it reduces the tax rate you would dinarily be charged on such income sales. This is facilitated by the double taxa on agreement in place between Ireland and the United States I wish f Wealth Op ons Ltd. /Wealth Op ons Trustees Ltd./ Conexim ( the Providers ) to make investments on the Wealth Op ons Broker Pla m. I understand that these investment may be made by a Unit Trust and may be subject to the provisions of the Trust Deed as amended. I consent to the Trustees/QFM applying f units in the Unit Trust on behalf of my pension/re rement fund I hereby consent to the provision of infma on to the Revenue Commissioners if required in rela on to this investment If I decide to exercise my cooling off op on on an insured product, my fund will be refunded less the adjustment f any downward movement in the unit price from the date of the investment to policy cancella on date By signing this fm I am indemnifying the Providers against any and all costs and claims incurred suffered arising directly indirectly out of the signing by the Providers of the Investment applica on and/ making the investment otherwise inconnec on with the investment.

4 Part 7 - Bene icial Owner Declarations (cont.) Data Protec on Acts The infma on that you have provided will be treated as confiden al and retained by the Providers f the purposes of financial services as required by law. You have a right to request a copy of the infma on we hold about you f which we may charge a small fee and to have any inaccuracies in your infma on crected. Wealth Op ons may use the infma on you have provided f the purposes of providing you with addi onal infma on rela ng to the goods and services of the Providers, it s associated companies and/ third par es. The Providers may share infma on with its associated and affiliated companies and/ carefully selected third par es, to enable those associated and affiliated companies and/ carefully selected third par es, to contact you directly in rela on to their goods and services. If you do not agree to the Providers use of the infma on f such purposes, please ck the box provided. Part 7 - Consent to Terms Befe comple ng and returning this fm please ensure that you have read and understood all infma on regarding your Wealth Op ons Broker Pla m Account and the Services you intend to avail of, including reading and understanding the Terms of Business, Risk Disclosure No ce, Summary of Conflict of Interest Policy and the Order Execu on Policy. Please sign below to confirm your consent to the terms and condi ons outlined in this document and in the Wealth Op ons Broker Pla m Terms of Business, and confirm that you are sa sfied that the investment you have requested is suitable f your needs and risk profile, and is consistent with the le er/statement of suitability I have received from my broker/financial advis. Execu ve Pension Member Trustee: Execu ve Pension Pensioneer Trustee: A(M)RF Holder: QFM: PRB Bondholder: PRB Trustee: Personal Pension Holder: Personal Pension Trustee: Intermediary Declara on I declare that I have met the above named applicants and have explained the relevant investments on the Wealth Op ons Broker Pla m to them and am sa sfied that it is suitable f their needs and risk profile. I can confirm that we have fully complied with An Money Laundering and Terrist Financing Legisla on. Financial Broker Name: Financial Broker Signature: Financial Broker Firm: Date:

5 Part 8 - Identity Documentation In der to comply with An -Money Laundering and Terrist Financing regula ons Wealth Op ons and Conexim Adviss Ltd. require the following in der to verify your name and address. Please provide the documenta on as outlined below. Name Verifica on A cer fied copy of current valid passpt full Irish drivers license. (A cer fied copy is one that has been signed and stamped as a true copy of the iginal by a regulated en ty, a solicit, commissioner f Oaths, Garda, chartered accountant, bank official, another designated person as understood under The Criminal Jus ce (Money Laundering and Terrist Financing) Act 2010 (as amended). Address Verifica on Two fms of proof of address, which can include: U lity Bill (Gas, electricity, local authity bill, landline telephone bill etc. - no mobile phone bills will be accepted) Bank statement, credit union statement credit card bill, Current balancing statement from Revenue Commissioners Social insurance documents Current Household/mot insurance documents (a quota on is not acceptable) No fica on of Determina on of Tax Credits Tax Clearance Cer ficate (An iginal cer fied copy of each item above is accepted and must be less than three months old) Address: Unit 1C Elm House Millennium Park Naas Co Kildare Tel: Fax: Website: Wealth Options Broker Platfm is a trading name of Conexim Adviss Ltd. Wealth Options Ltd. & Conexim Adviss Ltd. are regulated by the Central Bank of Ireland Wealth Options Ltd. Registered in Ireland No: Conexim Adviss Ltd. Registered in Ireland No: Product providers f financial adviss

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