DOB: Investor's Notepad - Form


Date: Time: {check} Call made     {check} Call received    {check} Meeting
Broker's Name: Telephone number:
Broker's Firm:
Investment Recommendation:

Buy:  {check}   Sell: {check}

Name of security:


Reason for broker's recommendation:



How does this investment meet my financial goals?


What are the risks associated with this investment?


Proposed Trade:

Number of shares/units:

Price per share: $

Total cost: $

Agent's Commission:

My Instructions:

Do nothing: {check} Buy:   {check}   Sell: {check}

Number of shares/units:

Price per share: $

I asked for written information about the investment before I made a decision.

Yes:  {check} No:  {check}

Before investing, I will receive a:

Prospectus:  {check}

Offering Memorandum:  {check}

Most recent annual report: {check}  

Most recent quarterly report:  {check}

Research report:  {check}

Other info:  {check}