Private Clients

• Brokerage Account
• Wealth Management

Brokerage Account Opening Application for Individuals

Two easy ways to open account with us:

• 1.  Fill in this application (, .pdf, 300 kb) and sent a hard copy to the following address:
         77-A Chervonoarmiyska St., 2nd floor, Kyiv 03150, Ukraine.
  or
• 2.  Fill in the parts of the online form with Account Opening Information:

Step #1

Inportant Notices     Risc Disclosure Statement

I. Identification and client information

Full name:

Registered Address:

Mailing Address
(if different):

Phone Number:

Fax Number:

URL:

E-mail:

Passport/Personal ID Card Details:

Number:

Number:

Number:

Mailing Address
(if different):

Number:

Mailing Address
(if different):

Number:

Do you currently have any pending litigation in Georgia, or have you ever had litigation, disputed accounts, or unresolved matters with a Georgian or other broker, investment firm, custodian, stock exchange or investment advisor?

No Yes

If Yes, please provide details:

Have you, or a firm in which you were a senior officer, ever been convicted of a crime?

No Yes

If Yes, please provide details:

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Clear

Step #2

Inportant Notices     Risc Disclosure Statement

II. Authorizations

Person(s) authorized to give us trade and transfer orders (if different from account holder)

1. Name:

Phone number:

E-mail:

URL:

Acting as authorized by:

Please attach duly executed evidence of authorization:

2. Name:

Phone number:

E-mail:

URL:

Acting as authorized by:

Please attach duly executed evidence of authorization:

III. Settlements and Account Information

Bank Transfer Instructions:

IV. Required KYC Documentation for Individuals

Copy of the information page of your passport or other ID documents containing your photo and signature*:

* Documents should be duly notarized and apostilled.

Copy of the Georgian Taxpayer’s Certificate**:

** If client doesn’t have Georgian Taxpayer’s ID, Galt & Taggart Securities is required by Georgian Law to withhold from the client capital gain and other applicable taxes upon completion of transaction.

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Clear

Step #3 (optional)

Inportant Notices     Risc Disclosure Statement

V. References, Investment Objectives, Qualifications and Experience

1. What is your primary occupation?

2. Is your occupation your primary source of income?

Yes No

If No, what is your primary source of income?

3. Are you employed by a firm that has as its primary business
dealing in investments or securities?

Yes No

If Yes, which firm?

4. Are you personally acquainted with an employee or employees
of our company, or any of its affiliated companies?

Yes No

If Yes, please provide the name:

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5. How would you characterize your experience with securities?

extensive moderate

little no experience

6. Which of the following represents your investment objectives or needs?

long-term investment short-term speculation

investing for capital gains investing for current income managing liquidity

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7. Have you ever invested or speculated in any of the following instruments or activities? (check those that apply)

publicly-traded equities commodities contracts promissory notes

stock borrowing and lending limited partnership interests publicly-traded corporate deb

privatization/auction participation life or property insurance currencies contracts

money-market funds margin trading mutual funds repos

exchange–traded options on underlying securities or indices exchange-traded futures on underlying securities or indices

other instruments government or municipal bonds:
(please indicate

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8. Which amount do you intend to invest in?

From (USD):	1,000	50,000	100,000	500,000	1,000,000	More
To (USD):	50,000	100,000	500,000	1,000,000	10,000,000	More

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9. What are your needs for custody services? Depo (nominee) account with us No need for custody services:
(please indicate)

10. What is the anticipated average size and holding period of your positions in securities?

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VI. Investment Strategy and Business Information

Are you acting as a nominee/agent/trustee for another individual,
group or entity?

Yes No

If Yes, please identify

Do you maintain an account or a beneficial interest in an account
held with us, or any of our affiliated entities, under another name?

No Yes

If Yes, please provide details

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Clear