Power Of Attorney Certification Form
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3Power of Attorney Certification
The undersigned account owner (Principal) and individual appointed by Principal to act on his/her behalf (Agent) pursuant to a duly executed Power
of Attorney (POA) Agreement hereby provide this Power of Attorney Certification (Certification) to Scottrade, Inc. or its affiliates (together
Scottrade). The Principal and Agent acknowledge and understand that Scottrade has the right to rely solely on the representations made by the
Principal and Agent in this Certification. In the event the Principal is disabled or incapacitated and unable to execute this Certification, the Agent is
requesting Scottrade recognize his/her authority to act on behalf of the Principal. The parties represent and affirm that the underlying POA is
general and durable in nature. Scottrade does not currently accept limited or springing POAs.
Every field below must be completed prior to submitting this Certification. Failure to provide the information requested below may result in Scottrade
declining to permit the Agent to act in the account in any manner. Please note that Scottrade only accepts Certifications for individual, joint, and IRA account types.
Principal Information
Scottrade Account Title
Scottrade Account Number
Scottrade Account Title
Scottrade Account Number
Scottrade Account Title
Scottrade Account Number
Scottrade Account Title
Scottrade Account Number
For joint accounts, please state which Principal (Account Owner) the POA covers.
If the Principal has appointed two or more Agents, the Agents will have identical powers. They are authorized to act alone and without the consent of the other
Agent or Agents. However, Scottrade may, in its sole discretion, restrict the Account from activity in the event the Agents enter conflicting or inconsistent
instructions. In addition, Scottrade may request additional documentation from a Principal or Agent prior to executing any transactions requested by the Agents(s).
Agent Information
(If multiple Agents intend to act on the account(s) listed above, each Agent must complete a separate Certification.)
Full Legal Name
Social Security or Tax ID Number
Date of Birth
Street Address
Email Address
City
State
ZIP/Postal Code
Primary Phone Number
Secondary Phone Number
US Citizen?
YES
NO - Indicate Country of Citizenship
Alien Registration Number
Country of Citizenship:
YES -
NO -
Indicate your Visa type and provide proof of legal status
Occupation
Employment
Employed
Homemaker
Self-employed
Student
Unemployed
Retired
Employer
Employer Address
Are you employed by or affiliated with a securities firm, a stock exchange, or FINRA?
YES
NO
If yes, provide name and address of Compliance Department in the space below.
Are you an officer, director, affiliate or 10% shareholder of a publicly traded company?
YES
NO
If yes, provide symbol and CUSIP# of company in the space below.
Are you a state or federally registered investment advisor?
YES
NO
If yes, provide employer name and address in the space below
NO Is any applicant or member of immediate family or business associate a senior foreign political official?
YES
If yes, provide employer name and address in the space below:
Agent's relationship to the Principal:
Spouse/Domestic Partner
Immediate Relative
Extended Relative
Investment Advisor
CPA
Attorney
Other, please specify:
Powers Granted to Agent by Power of Attorney Agreement:
By executing this form the Principal and Agent each represent, acknowledge, and affirm the following:
The POA Agreement is general and durable.
POA Execution Date
**EX1326**
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SF1592/9-14
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