Initial Data Gathering Form

Jeff White, CFP

Koko Marina Center, G-205

7192 Kalanianaole Highway

Honolulu, Hawai’i  96825-1845

Phone (808)395-0200 / Fax (808)395-0225


I’d like to make your life a bit more convenient.

Beginning a new investment program requires the completion of multiple forms.  Many of the forms require the same information to be completed.  In order to have more time at our meeting to address your questions (instead of completing forms), we’ll complete all required forms in advance if you’ll take a minute now and provide the following information.   All information remains confidential and will not be disclosed without your consent.

This document will NOT enroll you in any program.

Full Legal Name:                                                                                                                                    

                          First                                               Middle Initial                                            Last

Social Security Number:                                                 Date of Birth:                                                  

Residence Address:                                                                                                              _______

                             Street Address                       City                                  State                  Zip Code

Mailing Address:                                                                                                                                  _

                            Street Address                        City                                  State                  Zip Code


Home Phone:                          Work Phone:                       Cell/Pager/Other: ______________

Email Address:                                              Fax:                                                                                   

Employer:                                                                     Job Title:                                                             

Employer Address:                                                                                                                 _______ 

                                 Street Address                   City                                  State                  Zip Code   

                                                                                                             Marital Status

            /           /                                                                             Married: _____    Single:  _____      

     Date of Hire                                                                                                      

                                                                                                              # of Exemptions                   

Current Pay  - Hourly ________ or Annually _______________     Fed________ State________

All Financial Organizations are required to review your Gov’t Issued Photo ID (E.g. Driver’s License) before opening a New Account. Please attach a copy or have one handy when we meet.

Driver’s License or other Government Issued ID:   Issue Date:   /           /                         Type:___________________                 Issuing State/Country______________                     ID#:__________________________                       Exp. Date___/___/_______

 US Citizen (Y/N)___________________

FINRA requires us to have a clear picture of our client’s assets. Please indicate approximate amount of assets you own in each category and how many years you have been investing into this category -

Cash and Checking                                   $                   


Mutual Funds $          Years
Annuities $          Years
Bonds $          Years
Equities/Stocks $          Years
Margin $          Years
Partnerships/REITS $          Years
Cash Value Life Insurance $          Years
Real Estate $          Years


Please fax completed form to my office at (808) 395-0225.or email to

  Mahalo for your time!