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1 Brokerage Account 1 Specify type of account ownership (Please attach necessary documents.) ( Minimum opening balance of $1,000 in cash and/or securities is required.) Select the type of account ownership: (Please check one box.) Individual/sole proprietor account Questions? For Prudential use only: Call Prudential Retirement Office F at (fax: ) Limited liability company. Enter the tax classification (C=C Corporation, S=S Corporation, P=Partnership) Investment Club Complete investment club authorization. Joint account Tenants with right of survivorship Joint account Tenants in common (In the event of the death of either or any of the undersigned, the interest in the tenancy shall be equal unless otherwise specified.) Custodial account List only one custodian for the benefit of one minor. (See Section 2) Trust Include Trustee Certification of Investment Powers form. C Corporation Include corporate resolution. S Corporation Include corporate resolution. Partnership Complete partnership authorization. Estate Include estate papers. Association or non-corporate organization Provide resolution. Other Are you a Prudential Financial employee? Yes No Do you have an existing account with Prudential Investment Management Services LLC? Yes No Please notify us if you have multiple accounts that should be linked for qualification of reduced sales charges on front-end loaded mutual funds (please refer to the fund s prospectus for this qualification). Without this information we cannot identify and link related accounts held outside and, in some cases, held within Prudential Investment Management Services LLC. The investor may not realize the full breakpoint opportunity available without this information. Account number(s) 2 Provide account holder information (Please attach necessary documents.) Individual or joint account holder s information: Account holder name Social Security no. of birth Home phone no. Drivers license no. State Issue date Expiration date Or Passport no. Country Expiration date Mailing Legal (If mailing is a P.O. Box, you must provide a legal street.) U.S. citizen Yes No Other Non-resident alien? (If yes, W-8 form is required.) Yes No Marital status: Single Married Widowed Divorced Number of dependents Joint account holder s information: (If applicable.) Account holder name Social Security no. of birth Home phone no. Drivers license no. State Issue date Expiration date Or Passport no. Country Expiration date 1

2 Provide account holder information (Continued) Mailing Legal (If mailing is a P.O. Box, you must provide a legal street.) U.S. citizen Yes No Other Non-resident alien? (If yes, W-8 form is required.) Yes No Marital status: Single Married Widowed Divorced Number of dependents Custodial account: Name of minor if custodial account Minor s Social Security no. Custodian s Social Security no. of birth of minor Custodian name Provide additional information (Must be completed to open an account.) Individual or joint account holder s information: Employed by Business street (PO Box not allowed) Occupation Business phone no. (Required) If self-employed, what is the nature of your business? If not employed, are you retired, a student, etc.? Joint account holder s information: (If applicable.) Employed by Business street (PO Box not allowed) Occupation Business phone no. (Required) If self-employed, what is the nature of your business? If not employed, are you retired, a student, etc.? Affiliation disclosure: (please complete the section below) Is any account holder affiliated with or employed by a member firm of a stock exchange or FINRA; a senior officer of a bank, S&L, insurance company, registered investment company, or registered investment advisory firm; or in the securities department of any of the above or an immediate family member of any such person? Yes No If yes, list company name and position. Is any account holder or anyone with an interest in the account a director, a 10% shareholder, or a policy-making executive officer of a publicly traded company? Yes No If yes, list company. 2

3 3 Client profile information This portion of the application must be fully completed. Industry regulation requires us to obtain certain information to verify identification and to determine suitability of this account. Incomplete information will prevent this application from being considered in good order and will delay opening your account. Prudential Financial cannot be held responsible for any delays in opening your account if information on this application is incomplete. Income Net worth Check one box. See definitions below if you have any questions. Ranges Annual income (all sources) Check one box in each column. See definitions below if you have any questions. Ranges Net worth (assets minus liabilities) Liquid net worth (exclude non-liquid assets) $0 24,999 c $0 49,999 c c $25,000 49,999 c $50,000 99,999 c c $50,000 99,999 c $100, ,999 c c $100,000 + c $500,000 + c c Owner s tax bracket: % (Approximate federal income tax bracket, based on previous year s tax return.) Definitions Annual income (all sources): Annual gross income, before any deductions for income taxes or qualified plan contributions, etc. Net worth (assets minus liabilities): Your assets minus liabilities; include all investments and all liabilities. The value of everything you own less everything you owe. Liquid net worth: Your assets that can be converted easily to cash without incurring a penalty or loss of principal. This includes cash, savings accounts or cash equivalents such as the cash value of a life insurance policy. Investment objectives Please rank your investment objectives in order as they relate to the assets in your brokerage account from 1 (most important) to 5 (least important). c Preservation of capital c Income c Capital appreciation c Speculation c Trading profits Investor style Please select ONE description that best represents your investment approach to this account. c Conservative Prefer little risk and low volatility in return for accepting potential lower returns. Minimizing exposure of principal to loss or fluctuation is very important. c Moderate Willing to assume an average amount of market risk and volatility or loss of principal to achieve higher returns. c Aggressive Willing to sustain volatility or loss of principal and assume a high level of risk in pursuing higher returns. Investment experience Please indicate your years of experience with the following investment types (if no experience, please enter zero). c Equities c Options c Bonds c Variable contracts c Mutual funds c Limited partnerships 3

4 Client profile information (Continued) Years to retirement: Please indicate the number of years until you need access to the assets in this brokerage account. 0 5 years 6 10 years years 16+ years Source of funds for this account: Please indicate the source of funds for this brokerage account below. Check all that apply. If any of the following options are selected, with the exception of Other, an Investment switch form must be completed, signed, and returned with this application. If Other is selected, please contact Prudential Retirement to determine if a switch form needs to be returned with this application. Please note: Your non-retirement account will not be established until Prudential Investment Management Services LLC ( PIMS ) has received your non-retirement application (Brokerage account application) and determined that it is complete and in good order (in some cases, this may require a Prudential representative to collect more information from you). Mutual funds (includes no-load funds) Unit investment trust Variable annuity Fixed annuity 529 Plan Life insurance cash value Life insurance death benefits Other 4 Select cash management option To add check writing and a VISA Gold check card to this brokerage account, please fill out the additional customer information below, and make sure the information in Section 2 of this application is as you would like it to appear on your checks and VISA Gold check card(s). (Minimum balance of $5,000 in cash and/or securities and a margin account agreement are required. Your account will be charged $5 per month.) Checking and VISA Gold check card information: Would you like your phone number included on your checks? Yes No Please select the check style you prefer: Personal Corporate I (We) hereby apply for check writing and VISA Gold check card privileges. I understand that checks and charges on my VISA Gold check card(s) will be drawn on assets held in my brokerage account to the extent necessary to cover such checks and VISA Gold check card charges. Please indicate the number of VISA Gold Check Cards requested: Applicant Joint applicant Please choose one of the following Fidelity money market funds. (Please read the fund s prospectus carefully before you invest.) Prime fund Tax-exempt fund Previous Mother s maiden name (Other than PO Box and if less than 3 years at current.) Joint applicant s information: (If applicable.) Previous Mother s maiden name (Other than PO Box and if less than 3 years at current.) 4

5 5 Provide investment instructions Important note: Accounts with balances below $1,000 may be closed at our discretion. To allocate portions of your assets to specific mutual funds, use the spaces below to specify the funds, and the percentage or dollar amount (if applicable) of your assets you would like to invest. For the names of no-load, no-transaction-fee funds, contact Prudential Retirement at Please note: Once you accumulate enough cash to meet your chosen funds minimum purchase requirements, please call us at so that we may invest in the fund(s) you have selected. Until that time, if you have chosen the Cash Management feature, your assets will be invested in the Fidelity money market fund you selected in Section 4 (i.e., Prime fund or Tax-exempt fund). Please read the fund s prospectus before investing. If you did not choose the Cash Management feature, your assets will be invested in the Money account. Option 1: If you are enclosing a check for the full amount of your initial contribution, please use the spaces below to list your mutual fund choices and allocation percentages for each fund. Please Note: If you are sending a lump sum, attach a check made payable to Prudential Retirement. Name of fund Symbol Percent Name of fund Symbol Percent % % % % % % % % 6 Option 2: If you would like to purchase securities other than mutual funds (e.g., stocks, bonds, CDs, etc.) or if you would like to discuss your investment choices with one of our Retirement Counselor(s), please check this box. Your assets will be invested in the Money account and a Retirement Counselor(s) will call you when your account has been opened to discuss the securities you would like to purchase. Please note that we will contact you at the phone number provided in Section 2. Our ability to contact you will determine the timing of your order to purchase securities. Specify service instructions 1) Settlement instructions: (When you sell a security, please choose how you would like the proceeds distributed.) Deposit the proceeds into my account and invest them in the Money account. Please send me a check. 2) Cash dividends/interest: (If your securities generate returns in the form of dividends or interest, please choose how you would like these proceeds distributed.) Deposit the dividends or interest into my account and invest them in the Money account. Please reinvest my dividends if reinvestment is available. Check here if you do not want your name,, and securities positions disclosed to any of the companies in which you own securities that are being held in this account. Please note: If you have chosen the Cash Management feature, any proceeds, dividends or interest will be invested in the Fidelity money market fund you selected in Section 4 (i.e., Prime Fund or Tax-Exempt Fund). Please read the fund s prospectus before investing. If you did not choose the Cash Management feature, your assets will be invested in the Money account. 3) Duplicate confirmations (optional): Send duplicate confirmations to: Street 5

6 7 Sign and date this form I hereby apply for a securities account ( Securities account ) under the terms and conditions set forth in the Customer Agreement (the Agreement ) and agree to be bound thereby. I am authorized to enter into the Agreement and have obtained and will provide you with all necessary authorizations from third parties to open accounts and effect securities transactions under the Agreement. I will be the owner of all securities purchased, held, and sold by me through you, or will otherwise have the authority to purchase, hold, or sell such securities. I understand that you entered into an agreement with National Financial Services LLC (NFS) to execute and clear securities transactions in my Securities account. I further understand and agree that NFS will carry and maintain my Securities account, except as may otherwise be provided in the Agreement. I understand and agree that, for our mutual protection, you and NFS may record any of our telephone conversations without further notice. I also understand that all transactions shall be subject to rules, regulations, customs, and usages of the exchange, market, or clearinghouse where executed, and to all applicable federal and state laws and regulations. I will not buy, sell, or liquidate any securities of a corporation of which I am an affiliate, or sell or liquidate any restricted securities, except in compliance with applicable laws and regulations and with notice, to you, that the securities are restricted. I have reviewed the information contained on this application and attest to the accuracy thereof. Under penalties of perjury, I certify that: (1) The number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. citizen or other U.S. person As an applicant for the Cash Management option, I certify that: (Check all boxes below.) (1) I understand that I am applying for a Margin account, which involves the extension of credit. (2) I (We) have read, understand and agree with the NFS and Cash Management provisions as set forth in the Customer agreement. My (Our) signature(s) will serve as checking account verification, and I (we) understand that only one signature is required on checks. (3) I (We) hereby acknowledge that I (we) have read, understand and agree to the terms and conditions set forth in the enclosed Customer agreement/margin agreement. I understand that available free credit balances in my account will be automatically invested or deposited in a Money account. This Money account may be a money market mutual fund, an FDIC-insured bank deposit or such other arrangement as you may establish from time-to-time. I agree that you may, at your discretion, change the Money account by providing me with advance written notice of such change. In the event that you elect to change the Money account, I authorize you to redeem or withdraw any funds held in the prior Money account and reinvest them into the new Money account. I understand that Brokerage investments are not insured by the FDIC, are not deposits or other obligations, unless stated otherwise, of any bank, and are subject to investment risks including possible loss of principal invested. The securities in your account are protected in accordance with the Securities Investor Protection Corporation (SIPC). For more details on SIPC, or to request a SIPC brochure, visit or call To help the U.S. government fight the funding of terrorism and money-laundering activities, Federal law requires that Prudential Retirement obtain, verify, and record information that identifies each person who opens an account. What does this mean for you? When you open an account, we will ask for your name,, date of birth and other information that will allow us to verify your identity. I understand that the Customer Agreement contains a pre-dispute arbitration clause (section 15, beginning on page 2) requiring all disputes under the Agreement to be settled by binding arbitration. By signing below, I acknowledge receiving a copy of the Customer Agreement and agree to be bound by its terms and conditions. The Internal Revenue Service does not require your consent to any provision of the document other than the certifications required to avoid backup withholding. Account holder s signature Print account holder s name Joint account holder s signature Print joint account holder s name 6

7 For Prudential use only Registered representative s signature Print registered representative s name Signature of supervisory principal Print name of supervisory principal F73 Office Reg. rep. no. Account no. account opened 7

8 Return standard mail to: Prudential Retirement Return Overnight mail to: } } } 30 Scranton Office Park Prudential Retirement PO Box 5320 Scranton, PA Scranton, PA Fax To: Securities products are not FDIC insured/not bank deposits/may lose value Accounts are carried by National Financial Services LLC, Member NYSE/SIPC. Securities products and services are offered by Prudential Investment Management Services LLC (PIMS), Three Gateway Center, 14th Floor, Newark, NJ , a Prudential Financial company. Retirement Counselors are registered representatives of PIMS. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. 30 Scranton Office Park Scranton, PA RSFM014 Printed 04/2012

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