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Product Application Form Fusion Managed Portfolio PAF2


Account Reference 1

Account Name

(for internal use only)

Please complete this section indicating how you wish to have the account registered/recorded for future reference

Account Name

2

Applicant Details

First Applicant Title

Forename(s)

Surname

Forename(s)

Surname

Trust Name Company Name Second Applicant Title

3

Investment Details

Strategy Decision (delete as appropriate) Income

Investment Amount Alpha

Portfolios may choose to have distributions and income

4

Plus

Reporting Currency Paid out

Sterling / US Dollars / Euros

or

Retained for investment

Source of Funds

The funds to be invested with Capital International Limited are to originate from: (please state bank or building society name and address)

Source of Funds

5

Source of Wealth

Please indicate the underlying source of your wealth, e.g. if your wealth is derived from salary/bonus please give an indication of your annualised salary I/We confirm that the source of my/our wealth represented by the funds to be held in this account derive from:

Description

Amount / Value

Details

Business Profits Life Savings Salary/Bonus Business Share/Sale House/Property Sale Pension Settlement Inheritance Other

Page 2

Please ensure all fields are completed to avoid delays in processing

Š Capital International Limited 2011


6

Declaration & Signature

You must sign and date the form below

I/We understand that the information I/we provide on this application form, and any additional information supplied, will be processed in accordance with Capital International Limited’s data protection statement contained in the Terms of Business referred to below. By signing below, I/we confirm that I/we have received the relevant documentation and advice relating to this investment, and Terms which I/we accept. I/We declare that: I/We am/are 18 years of age or over. I/We agree that the information contained within this application form is true and accurate. I/We have received, read and understood the Capital International Limited Fusion Managed Portfolio Service Brochure V1.01-08.10. I/We have received, read, understood and agree to be bound by the Capital International Limited Fusion Managed Portfolio Service Terms of Business V1.01-08.10 as set out in the accompanying documents. If you have not received all of the aforementioned documentation relating to the Capital International Limited Fusion Managed Portfolio Service, or do not fully understand the product offering then please contact your Financial Adviser or us immediately. Unless you were introduced by an Intermediary, Capital International Limited may use your personal information to tell you of other products and services, as well as others from within the Capital International Group of Companies, which they believe may be of interest to you. If you do not wish for your personal information to be used in this way, please put an X in this box.

Signing Authority (Joint Accounts)

Please indicate who Delete as appropriate - Signing Together / Signing Alone _______________________________

Signatures of ALL Applicants (YOU MUST SIGN HERE - Please ensure all relevant sections are completed as per the instructions on this form)

First Signature

PLEASE SIGN HERE Date

D D

Print Name

M M

2 0 Y Y

M M

2 0 Y Y

Second Signature

PLEASE SIGN HERE Date Print Name

Page 3

D D

Please ensure all fields are completed to avoid delays in processing

Š Capital International Limited 2011


7

Intermediary Details

This section should only be completed by Intermediaries. Please enter the appropriate details here and avoid supplying information on separate sheets.

Intermediary Name Intermediary Stamp/Details:

Registered Address Postcode I / we confirm that I / we am / are registered with / regulated by the following body to conduct investment business:

Firm Ref No I am/am not registered for VAT: Please tick the relevant commission structure:

X

A

X

B

C

X

D

Other:

.

If ‘Other’ is selected please specify the terms required on this application form; all terms must be agreed with Capital International Limited in advance.

Contact Name Telephone Number E-mail Address

Internal Use Only D D

M M

Acknowledged By:

Application Processed:

2 0 Y Y

D D

M M

Acknowledged By:

2 0 Y Y

Client Notification Sent:

D D

M M

2 0 Y Y

Acknowledged By:

CIL - Fusion PAF2 - V1.01-09.11

Received Date:


Capital International Product Application Form – PAF2