THIRD PARTY ACCESS AGREEMENT

1
1. ACCOUNT OWNER INFORMATION* This field is required.
NEW ACCOUNT
REVISION
REMOVAL
2
FULL NAME* This field is required.
3
IRA CLUB ACCOUNT NUMBER(S)
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LAST 4 OF SSN* This field is required.
5
PHONE NUMBER* This field is required.
6
THIRD PARTY: NAME OF DESIGNATED PARTY* This field is required.
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FIRM NAME (IF APPLICABLE)
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EMAIL
example@example.com
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PHONE NUMBER
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ACKNOWLEDGEMENT AND SIGNATURE* This field is required. I currently hold (or am now in the process of opening) an account with IRA Club. B. The designated third party on this form may seek information regarding the above-captioned account. C. The designated third party may not transfer funds, transfer assets, or authorize investment transactions on behalf of the account owner. D. As the account owner, I grant items B and C to the above named third party.
INDEFINITELY
UNTIL THIS DATE:
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UNTIL THIS DATE* This field is required.
Date
Month
Day
Year
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
Should be Empty: