EX-22.3 5 v05163_ex22c-iii.txt EXHIBIT 22(C)(III) [LOGO OF BRIDGES INVESTMENT FUND, INC.] NEW ACCOUNT APPLICATION Please do not use this form for IRA accounts.
Mail to: Bridges Investment Fund, Inc. Overnight Express Mail to: Bridges Investment Fund, Inc. c/o U.S. Bancorp Fund Services, LLC c/o U.S. Bancorp Fund Services, LLC PO Box 701 615 E. Michigan St. FL 3 Milwaukee, WI 53201-0701 Milwaukee, WI 53202-5207 For additional information, please call toll-free 1-866-934-4700. ------------------------------------------------------------------------------------------------------------------------------------ In compliance with the USA PATRIOT Act, all financial institutions (including mutual funds) are required to obtain, verify, and record the following information for all registered owners or others who may be authorized to act on an account: FULL NAME, DATE OF BIRTH, SOCIAL SECURITY NUMBER, AND PERMANENT STREET ADDRESS. CORPORATE, TRUST, AND OTHER ENTITY ACCOUNTS REQUIRE ADDITIONAL DOCUMENTATION. This information will be used to verify your true identity. We will return your application if any of this information is missing, and we may request additional information from you for verification purposes. In the rare event that we are unable to verify your identity, the Fund reserves the right to redeem your account at the current day's net asset value. ------------------------------------------------------------------------------------------------------------------------------------ 1. INVESTOR INFORMATION - SELECT ONE Individual ____________________________ _____ _________________________________________ __________________ FIRST NAME M.I. LAST NAME DOB (Mo / Dy / Yr) ____________________________ _________________________________________ __________________ SOCIAL SECURITY NUMBER DRIVER'S LICENSE OR STATE I.D. NUMBER STATE OF ISSUE Joint Owner ____________________________ _____ _________________________________________ __________________ FIRST NAME M.I. LAST NAME DOB (Mo / Dy / Yr) _____________________________ __________________________________________ SOCIAL SECURITY NUMBER DRIVER'S LICENSE OR STATE I.D. NUMBER STATE OF ISSUE Registration will be Joint Tenancy with Rights of Survivorship (JTWROS) unless otherwise specified. Gift to Minor ____________________________ _____ _________________________________________ __________________ CUSTODIAN'S FIRST NAME M.I. LAST NAME DOB (Mo / Dy / Yr) (ONLY ONE PERMITTED) ___________________________________ __________________________________________ __________________ CUSTODIAN'S SOCIAL SECURITY NUMBER DRIVER'S LICENSE OR STATE I.D. NUMBER STATE OF ISSUE ____________________________ _____ _________________________________________ __________________ MINOR'S FIRST NAME M.I. LAST NAME DOB (Mo / Dy / Yr) (ONLY ONE PERMITTED) ___________________________________ _______________________________ MINOR'S SOCIAL SECURITY NUMBER MINOR'S STATE OF RESIDENCE Corporation/ __________________________________________________________________________________________________________ Trust* NAME OF TRUST/CORPORATION/PARTNERSHIP AND STATE OF ORGANIZATION Partnership* __________________________________________________________________________________________________________ NAME(S) OF TRUSTEE(S) Other Entity* _____________________________________________ ___________________________________________________ SOCIAL SECURITY NUMBER / TAX ID NUMBER DATE OF AGREEMENT (Mo / Dy / Yr)
* You must supply documentation to substantiate existence of your organization (i.e. Articles of Incorporation / Formation / Organization, Trust Agreements, Partnership Agreement, or other official documents.) REMEMBER TO INCLUDE A SEPARATE SHEET DETAILING THE FULL NAME, DATE OF BIRTH, SOCIAL SECURITY NUMBER, AND PERMANENT STREET ADDRESS FOR ALL AUTHORIZED INDIVIDUALS.
2. PERMANENT STREET ADDRESS (PO Box is not acceptable) Mailing Address (if different from Permanent): (Residential Address or Principal Place of Business) If completed, this address will be used as the Address of Record for all statements, checks, and required mailings. __________________________________________ ____________ STREET APT / SUITE ____________________________ _____ __________ __________________________________________ ____________ CITY STATE ZIP CODE STREET APT / SUITE _______________________ ______________________ ____________________________ _____ __________ DAYTIME PHONE NUMBER EVENING PHONE NUMBER CITY STATE ZIP CODE ------------------------------------------------------------------------------------------------------------------------------------ Duplicate Statement #1 Duplicate Statement #2 Complete only if you wish someone other than the account Complete only if you wish someone other than the account owner(s) to receive duplicate statements. owner(s) to receive duplicate statements. __________________________________________ ____________ __________________________________________ ____________ STREET APT / SUITE STREET APT / SUITE ____________________________ _____ __________ ____________________________ _____ __________ CITY STATE ZIP CODE CITY STATE ZIP CODE ------------------------------------------------------------------------------------------------------------------------------------ 3. INVESTMENT AND By check: Make check payable to The Bridges Investment Fund, Inc. $ ________________ DISTRIBUTION OPTIONS ($1000 Minimum) By wire: Call 1-866-934-4700. Indicate amount of wire: $ __________________ Reinvest all Dividend and Capital Gain Distributions Reinvest all Dividend Distributions and Send Capital Gain Distributions in Cash Send Dividend and Capital Gain Distributions in Cash If nothing is selected, distributions will be reinvested. Cash distributions will be sent to the Address of Record given in Section 2 unless otherwise indicated. ------------------------------------------------------------------------------------------------------------------------------------ 4. AUTOMATIC INVESTMENT PLAN If you choose this option, funds will be automatically transferred from your bank account monthly. Please attach a voided check to Section 5 of this application. We Your signed application are unable to debit mutual fund or pass-through ("for further credit") accounts. must be received at least 15 business days prior to PLEASE KEEP IN MIND THAT: initial transaction. o There is a $25 fee if the automatic purchase cannot be made (assessed by redeeming shares from your account). o Participation in the plan will be terminated upon redemption of all shares. Amount per Draw ($100 Minimum) AIP Start Month AIP Start Day $_______________________________ ________________________________ _________________________________ ------------------------------------------------------------------------------------------------------------------------------------ 5. VOIDED CHECK FOR BANK INFORMATION If you have selected an automatic investment plan, please attach a voided check in this space. We are unable to PLEASE ATTACH debit or credit mutual fund or VOIDED CHECK pass-through accounts. HERE Please contact your financial institution to determine if it participates in the Automated Clearing House system (ACH).
6. SIGNATURE AND I have received and understand the prospectus for The Bridges Investment Fund, Inc. (the "Fund"). CERTIFICATION I understand the Fund's investment objectives and policies and agree to be bound by the terms of REQUIRED BY THE the prospectus. I acknowledge and consent to the householding (i.e. consolidation of mailings) of INTERNAL REVENUE regulatory documents such as prospectuses, shareholder reports, proxies, and other similar SERVICE documents. I may contact the Fund to revoke my consent. I agree to notify the Fund of any errors or discrepancies within 45 days after the date of the statement confirming a transaction. The statement will be deemed to be correct, and the Fund and its transfer agent shall not be liable if I fail to notify the Fund within such time period. I certify that I am of legal age and have legal capacity to make this purchase. The Fund, its transfer agent, and any officers, directors, employees, or agents of these entities (collectively " Bridges Investment Fund, Inc.") will not be responsible for banking system delays beyond their control. By completing sections 4 or 5, I authorize my bank to honor all entries to my bank account initiated through U.S. Bank, NA, on behalf of the applicable Fund. The Bridges Investment Fund, Inc. Fund will not be liable for acting upon instruction believed to be genuine and in accordance with the procedures described in the prospectus or the rules of the Automated Clearing House. When AIP transactions are presented, sufficient collected funds must be in my account to pay them. I agree that my bank's treatment and rights to respect each entry shall be the same as if it were signed by me personally. I agree that if any such entries are dishonored with good or sufficient cause, my bank shall be under no liability whatsoever. I further agree that any such authorization, unless previously terminated by my bank in writing, is to remain in effect until the Fund's transfer agent receives and has had reasonable amount of time to act upon a written notice of revocation. I authorize the Fund to perform a credit check based on the information provided, if necessary. UNDER PENALTY OF PERJURY, I CERTIFY THAT (1) THE SOCIAL SECURITY NUMBER OR TAXPAYER IDENTIFICATION NUMBER SHOWN ON THIS FORM IS MY CORRECT TAXPAYER IDENTIFICATION NUMBER, AND (2) I AM NOT SUBJECT TO BACKUP WITHHOLDING EITHER AS A RESULT OF A FAILURE TO REPORT ALL INTEREST OR DIVIDENDS, OR THE IRS HAS NOTIFIED ME THAT I AM NO LONGER SUBJECT TO BACKUP WITHHOLDING. (3) I AM A U.S. PERSON (INCLUDING A U.S. RESIDENT ALIEN). THE IRS DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHHOLDING. ___________________________________________________________ ________________________ SIGNATURE OF OWNER* DATE (Mo / Dy / Yr) ___________________________________________________________ ________________________ SIGNATURE OF OWNER* DATE (Mo / Dy / Yr) *If shares are to be registered in (1) joint names, both persons must sign, (2) a custodian for a minor, the custodian should sign, (3) a trust, the trustee(s) should sign, or (4) a corporation or other entity, an officer should sign and print name and title on the space provided for the Joint Owner. ------------------------------------------------------------------------------------------------------------------------------------ 7. DEALER INFORMATION _________________________________________________ ______________________________________________________ DEALER NAME REPRESENTATIVE'S LAST NAME FIRST NAME MI Please be sure to complete DEALER HEAD OFFICE INFORMATION: REPRESENTATIVE'S BRANCH OFFICE INFORMATION: representative's first name and _________________________________________________ ______________________________________________________ middle initial. ADDRESS ADDRESS _________________________________________________ ______________________________________________________ CITY / STATE / ZIP CITY / STATE / ZIP _________________________________________________ ______________________________________________________ TELEPHONE NUMBER TELEPHONE NUMBER ------------------------------------------------------------------------------------------------------------------------------------ BEFORE YOU MAIL, HAVE YOU: COMPLETED ALL USA PATRIOT ACT REQUIRED INFORMATION? ENCLOSED YOUR CHECK MADE PAYABLE TO THE BRIDGES INVESTMENT FUND, INC.? - SOCIAL SECURITY OR TAX ID NUMBER IN SECTION 1? INCLUDED A VOIDED CHECK, IF APPLICABLE? - BIRTH DATE IN SECTION 1? SIGNED YOUR APPLICATION IN SECTION 6? - FULL NAME IN SECTION 1? ENCLOSED ADDITIONAL DOCUMENTATION, IF APPLICABLE? - PERMANENT STREET ADDRESS IN SECTION 2?