This form contains 87 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Account Number
Account Number Text
Enter the account number for this account.
Max length: 11 characters
Account Registration Type
Individual/Joint Checkbox
Check this box if the account is registered as an individual or joint account.
Corporate Checkbox
Check this box if the account is registered as a corporate entity.
Investment Only Retirement Checkbox
Check this box if the account is an Investment Only, Non-prototype Retirement account where Fidelity Management Trust Company is not the trustee or custodian.
Fidelity Advisor IRAs Checkbox
Check this box if the account is a Fidelity Advisor IRA, including Traditional, Roth, Rollover, SIMPLE, SEP, or SARSEP/BDA types.
Fiduciary Checkbox
Check this box if the account is a Fiduciary account, such as a Trust, UGMA/UTMA, Estate, Conservatorship, or Guardianship.
Agent Authorization Action
Replacing All Agents Checkbox
Check this box if you are changing all previously authorized agents and replacing them with the agent(s) listed below.
Adding Agent Checkbox
Check this box if you are adding the person listed below as an Authorized Agent in addition to any agents previously authorized.
Authorized Agent 1 Signature Date
Authorized Agent 1 Signature Date Date
Enter the date when Authorized Agent 1 provided their signature.
Authorized Agent 2 Signature Date
Authorized Agent 2 Signature Date Date
Enter the date the Authorized Agent 2 signed the document.
Authorized Agent 3 Signature Date
Authorized Agent 3 Signature Date Date
Enter the date of the third authorized agent's signature.
Authorized Agent 4 Signature Date
Agent 4 Signature Date Date
Enter the date the Authorized Agent 4 signed this form.
Authorized Agent 5 Signature Date
Authorized Agent 5 Signature Date Date
Please enter the date the fifth authorized agent signed.
Fifth Authorized Individual
Fifth Authorized Individual First Name Text
Enter the first name of the fifth authorized individual.
Fifth Authorized Individual Middle Initial Text
Enter the middle initial of the fifth authorized individual.
Max length: 3 characters
Fifth Authorized Individual Last Name Text
Enter the last name of the fifth authorized individual.
Fifth Authorized Individual - Inquiry Only Checkbox
Check this box if the Fifth Authorized Individual is authorized for inquiry only (viewing balances, account history, and clerical information) and no financial transactions are permitted.
Fifth Authorized Individual - Limited Trading Authorization Checkbox
Check this box if the Fifth Authorized Individual is authorized for inquiry, trading (including exchanges and redemptions to registered account holder or pre-established bank), or for payment of advisory fees.
Fifth Authorized Individual - All Authorization Checkbox
Check this box if the Fifth Authorized Individual is authorized for all transactions, including purchases, redemptions, exchanges, transfers, and distributions to any party.
Fifth Authorized Individual SSN Text
Enter the Social Security Number of the fifth authorized individual.
Max length: 9 characters
Fifth Authorized Individual Date of Birth Date
Enter the date of birth for the fifth authorized individual.
Max length: 8 characters
Financial Advisor Information
Financial Advisor First Name Text
Enter the first name of the financial advisor.
Financial Advisor M.I. Text
Enter the middle initial of the financial advisor, if applicable.
Max length: 3 characters
Financial Advisor Last Name Text
Enter the last name of the financial advisor.
Financial Advisor Phone Text
Enter the phone number of the financial advisor.
Max length: 10 characters
Financial Advisor Fax Text
Enter the fax number of the financial advisor.
Max length: 10 characters
First Authorized Individual
First Authorized Individual First Name Text
Please enter the first name of the first authorized individual.
First Authorized Individual Middle Initial Text
Please enter the middle initial of the first authorized individual.
Max length: 3 characters
First Authorized Individual Last Name Text
Please enter the last name of the first authorized individual.
First Authorized Individual - Inquiry Only Checkbox
Check this box if the First Authorized Individual is authorized to only inquire about account information, such as viewing share balances and account history, with no financial transactions permitted.
First Authorized Individual - Limited Trading Authorization Checkbox
Check this box if the First Authorized Individual is authorized to inquire, trade within the account, and redeem mutual fund shares to the registered account holder or for payment of financial advisory fees.
First Authorized Individual - All Trading Authorization Checkbox
Check this box if the First Authorized Individual is authorized to inquire and request all types of transactions, including purchases, redemptions, exchanges, or transfers of shares.
First Authorized Individual SSN Text
Please enter the Social Security Number of the first authorized individual.
Max length: 9 characters
First Authorized Individual Date of Birth Date
Please enter the date of birth for the first authorized individual.
Max length: 8 characters
Fourth Authorized Individual
AP/AGT_AuthIndivFirstName04 Text
AP/AGT_AuthIndivMI04 Text
Max length: 3 characters
AP/AGT_AuthIndivLastName04 Text
Fourth Authorized Individual - Inquiry Only (I) Checkbox
Check this box if the fourth authorized individual should have Inquiry Only (I) authority.
Fourth Authorized Individual - Limited Trading (L) Checkbox
Check this box if the fourth authorized individual should have Limited Trading (L) authority.
Fourth Authorized Individual - All (A) Checkbox
Check this box if the fourth authorized individual should have All (A) trading authority.
AP/AGT_SSN_TIN04 Text
Max length: 9 characters
API/AGT_DOB04 Text
Max length: 8 characters
General
Print Button
Reset Button
Joint Owner Information
Joint Owner First Name Text
Enter the first name of the joint owner.
Joint Owner Middle Initial Text
Enter the middle initial of the joint owner.
Max length: 3 characters
Joint Owner Last Name Text
Enter the last name of the joint owner.
Joint Owner Mobile Phone Number Text
Enter the mobile phone number for the joint owner, which will be used as their primary phone number.
Max length: 10 characters
Joint Owner Email Address Text
Enter the email address for the joint owner.
Notarization 1
Notarization 1 State Text
Enter the state where the notarization is taking place for Notarization 1.
Notarization 1 County Text
Enter the county where the notarization is taking place for Notarization 1.
Notarization 1 Identification Text
Enter the identification details of the individual being notarized for Notarization 1.
Notarization 1 Printed Notary Name Text
Enter the printed name of the Notary Public for Notarization 1.
Notarization 1 Commission Expiration Date Date
Enter the date when the notary's commission expires for Notarization 1.
Max length: 8 characters
Notarization 1 Notary Signature Date Date
Enter the date the Notary Public signed the document for Notarization 1.
Notarization 2
Notarization 2 State Text
Enter the state where the notarization is taking place.
Notarization 2 County Text
Enter the county where the notarization is taking place.
Notarization 2 Identification Text
Provide details regarding the identification of the individual being notarized.
Notarization 2 Printed Notary Name Text
Enter the full printed name of the notary public.
Notarization 2 Commission Expiration Date Date
Provide the date when the notary public's commission expires.
Max length: 8 characters
Notarization 2 Notary Signature Date Date
Provide the date the notary public signed the document.
Page 4
SaD_PrintParticipantName Text
RO_Date Text
SaD_PrintParticipantName02 Text
RO_Date02 Text
Registered Owner Information
Registered Owner First Name Text
Enter the first name of the registered owner.
Registered Owner M.I. Text
Enter the middle initial of the registered owner.
Max length: 3 characters
Registered Owner Last Name or Organization Name Text
Enter the last name of the registered owner, or the name of the organization or trust if applicable.
Registered Owner SSN or TIN Text
Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of the registered owner.
Max length: 9 characters
Registered Owner Mobile Phone Number Text
Enter the primary mobile phone number for the registered owner.
Max length: 10 characters
Registered Owner Email Address Text
Enter the email address for the registered owner.
Second Authorized Individual
Second Authorized Individual First Name Text
Enter the first name of the second authorized individual.
Second Authorized Individual Middle Initial Text
Enter the middle initial of the second authorized individual.
Max length: 3 characters
Second Authorized Individual Last Name Text
Enter the last name of the second authorized individual.
Second Authorized Individual - Inquiry Only Checkbox
Check this box if the Second Authorized Individual is only permitted to inquire about the account (view balances, history, etc.) but cannot perform financial transactions.
Second Authorized Individual - Limited Trading Authorization Checkbox
Check this box if the Second Authorized Individual is permitted to inquire, trade in the account, including exchanges and redemption of mutual funds, or for payment of financial advisory service fees.
Second Authorized Individual - All Trading Authorization Checkbox
Check this box if the Second Authorized Individual is authorized to request all transactions, including purchases, redemptions, exchanges, or transfers of shares.
Second Authorized Individual SSN Text
Enter the Social Security Number of the second authorized individual.
Max length: 9 characters
Second Authorized Individual Date of Birth Date
Enter the date of birth for the second authorized individual.
Max length: 8 characters
Third Authorized Individual
Third Authorized Individual First Name Text
Enter the first name of the third authorized individual.
Third Authorized Individual Middle Initial Text
Enter the middle initial of the third authorized individual.
Max length: 3 characters
Third Authorized Individual Last Name Text
Enter the last name of the third authorized individual.
Third Individual - Inquiry Only Checkbox
Check this box if the third authorized individual should only be able to inquire about the account, such as viewing balances and account history, with no financial transactions permitted.
Third Individual - Limited Trading Authorization Checkbox
Check this box if the third authorized individual should be able to inquire and trade in the account, including exchanges, redemptions of mutual fund shares, or for the payment of financial advisory service fees.
Third Individual - All Trading Authorization Checkbox
Check this box if the third authorized individual should be able to request all transactions on the account, including purchases, redemptions, exchanges, or transfers of shares, with distributions payable to the registered account owner, the Authorized Agent, or any other third party.
Third Authorized Individual SSN Text
Enter the Social Security Number of the third authorized individual.
Max length: 9 characters
Third Authorized Individual Date of Birth Date
Enter the date of birth of the third authorized individual.
Max length: 8 characters