Client Information Form

(All information is held in strict confidence. A copy of our Privacy Policy is available here.)
For your safety, the form below is for your information only and is not fillable. For a fillable form, please click on one of the two links above.

	Client	Spouse
Full Legal Name
Social Security #
Date of Birth
Mailing Address
Home Phone
Cell Phone
Fax
Email Address
Occupation
Employer
Work Address
Work Phone
Marital Status
Check One	Driver's License Passport Government Issued ID	Driver's License Passport Government Issued ID
ID Number
Place of Issuance
Issue Date
Expiration Date
# of Dependants

FOR ERISA ACCOUNTS ONLY

(Defined Benefit Plan, Profit Sharing Plan, Money Purchase Pension Plan or 401k)

Tax ID Number
Corporate Representative
# of Participants
# of Key Employees
# of Meetings with Plan Participants per Year
Dates of Meetings with Plan Participants
# of Meetings with Board of Directors per Year
Dates of Meetings with Board of Directors
Fiscal Year End (Month)

OTHER ADVISORS: Please list the names and phone numbers of other advisors (i.e. accountants, attorneys, business managers, pension plan administrators, etc.) who have permission to request & receive financial information directly from WI.

Name	Phone Number

EMERGENCY CONTACT: Please list the name and phone number of the individual we should contact in the event of an emergency (i.e. death, hospitalization):

Name	Phone Number

Send form to:
Winans International
330 Ignacio Blvd #203
Novato, CA 94949
Or email to:
admin@winansintl.com
Or fax to:
(415) 883-1646