EmailMe Form - LOANS AGAINST STOCKS & BONDS

Name of Issuing Company: *

Applicant's Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Name in which the shares are registered:

Is the applicant a current shareholder? *

Yes

No

If yes, what percentage is owned?

About the Stock

Symbol: *

Exchange: *

Current Bid: *

Market Cap: *

Date of Issue: *

Average Daily Volume: *

Last 30 Days

Number of Shares Authorized: *

Number of Shares Outstanding: *

Number of Shares in Float: *

Number of Shares Available for Loan: *

Is the stock pledged for private placement, institutional sale, cross collateralized, or subject to any other liens, mortgages[s], re-hypothecation, or otherwise encumbered in any fashion? *

Yes

No

If Yes, please describe:

When was the stock acquired? *

How was the stock acquired? *

Is the stock Free-Trading? *

Yes

No

Is the stock Restricted? *

Yes

No

If Yes, explain why:

Restriction Expires:

if applicable

Additional comments, if any:

SIGNATURE

Name of person completing the form: *

Phone: *

Email: *

Confirm

Person completing the form is: *

Broker

Principal Borrower(s)

Other

Name of person who referred you to us (if applicable):

(if applicable)

Email of person who referred you to us:

A copy of this application will be sent to them.

ACCOUNT EXECUTIVE

If you have been assigned an Account Executive (Other than the person who referred you), please enter their email address here:

Account Executive email (if applicable):

A copy of this application will be sent to them.