Portfolio Review Form

Ascani Wealth Management provides free, no-obligation portfolio reviews for investors who provide us with information. In order to review your portfolio, please provide us with the following information so that we may contact you. If you do not want to fill out this form online, you may print it out and fax it to us at 561-253-8155 or call us at 1-877-578-5788 (international call 561-578-6678) to speak to one of our financial advisors.

Please complete the form below for a no cost, no obligation portfolio review.

Title: Mr. Mrs Ms
First Name:	Last Name
Phone:	Fax:
Street Address:	Email:
City:
State:
Zip:
Joint Tenant Name	Corporate/Trust Name
Retired? Yes No
Age:
How did you hear about Ascani Wealth Management?	Select from list Google yahoo Word of mouth Radio program Email marketing
Portfolio Objective
Conservative: I want to use my portfolio to build wealth slowly while also preserving my principal. Moderate: I need a balance of current income and growth of my principal. I can tolerate moderate fluctations in my portfolio in attempting to achieve my goals. Aggressive: My objective is growth of my principal in the pursuit of maximizing returns in order to build wealth for my retirement years. I understand that the pursuit of this objective may entail a greater potential loss of principal.
Are you a high net worth investor?	Yes No
Experience	Stocks Bonds Options Futures
Total Investment Size	How do you make your investment decisions?
$100,000 - $500,000 $500,000 - $1,000,000 $1,000,000 - $3,000,000 3,000,000 - $5,000,000 $5,000,000+	I closely watch the market and conduct my own research on mutual funds. Watching the market is very enjoyable, but burdensome and confusing. I am a long term investor, no reason to make changes to my portfolio. I have an investment advisor who helps me make decisions. I do not have time to make investment decisions.
Describe your relationship with your current advisor (Check all that apply)
I do not have an advisor, but I am looking for one I do not have an advisor, and I would not use one I do not have an advisor, but I am interested in learning how one might help me with my investments. I have a good relationship with my advisor, I will work with him/her for years to come. I have a good relationship with my advisor, but I have another portion of my portfolio that help. I have a poor relationship with my advisor.
How would you like Ascani Wealth Management to help you with your portfolio? (Check all that apply)
I need help improving my investment returns I do not have the time to monitor my portfolio I need to use my portfolio to supplement my income. I understand that my portfolio deserves constant attention, but I do not want to spend the time monitoring it. I am not interested in having someone manage my portfolio but would like your recommendations on what to buy and sell
What types of accounts do you currently have, or are considering opening? (Check all that apply)
IRA Trust Keogh 401-k 403(b) Joint Account Corporate Account
I am primarily concerned about the following. (Check all that apply)
Preservation of a significant lump-sum distribution from the sale, inheritance or a bonus Reaction to unsettling market volatility. Improving investment results. Lack of time to manage portfolio effectively. Require investment management due to untimely life event/survivorship issues IRA, 401(k) or 403(b) account management Diversification into other asset classes such as gold funds or income funds
Please let us know if you have any other questions or comments