CB3 Financial Group, Inc.

Personal Data Survey

Please supply CB3 with this information so that we may pre-fill your new investment account application. Having this information ahead of the application signing meeting will greatly help us in processing your application quickly and accurately.

Contact Information

Name: *

Full name with middle initial

Address: *

City: *

State: *

ZIP: *

Home Telephone: *

Cell Phone Number:

E-mail Address: *

Personal Information

Social Security Number: *

Birthdate: *

Wedding Anniversary:

Approximate Net Worth: *

Liquid Assets (without your home): *

Tax bracket as filed on most recent 1040: *

Business Information

Name of Business Where Employed: *

Address: *

City: *

State: *

ZIP: *

Business Telephone: *

Position Held at the Business: *

Annual income: *

Type of Business: *

Years employed: *

Beneficiary Information

Beneficiary’s name(s), full address(es), relationship(s), social security number(s), and birthdate(s): *