Fillable Certificate Request Form printable pdf download

Certificate Request Form

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Complete Certificate Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Certificate Request

SCOTTRADE ACCOUNT HOLDER INFORMATION

Account Title

Account Number

Account Holder Social Security or Tax ID Number

Joint Account Holder Social Security or Tax ID Number

SECURITY INFORMATION

Security Name

Symbol

CUSIP

TO BE RE-REGISTERED TO

Complete if the shares are to be registered in a name other than how the Scottrade

customer account is currently registered.

Account Holder Name (First, Middle, Last)

Joint Account Holder Name (First, Middle, Last)

Social Security or Tax ID Number

Date of Birth

Social Security or Tax ID Number

Date of Birth

Address

Reason for Request

Your Relationship to New Registrant

Custodian Name (If applicable)

Social Security or Tax ID Number

Date of Birth

Custodian Address

Trust Name and Under Agreement Date (If applicable)

COST BASIS

If the securities you are transferring are part of a larger position that was purchased in multiple tax lots, the default method for determining which shares to transfer is First-In, First-Out

(FIFO), unless you have previously specified a different global tax strategy that will implement another method. To specify the transfer of alternate shares, complete the section below.

Symbol

Number of Shares Acquired Date Average Unit Cost

Symbol

Number of Shares Acquired Date Average Unit Cost

If applicable, indicate transaction type:

Inheritance

Gift

I give Scottrade, Inc. the permission to have a certificate created with the registration provided above. I acknowledge a

fee will be charged to my Scottrade

account.

Account Holder's Signature

Date