Product Application Form Fusion Managed Portfolio

PAF2

Please ensure all fields are completed to avoid delays in processing © Capital International Limited 2011 Page 2

3 Investment Details

Investment Amount

Reporting Currency Sterling / US Dollars / Euros

Portfolios may choose to have distributions and income Paid out or Retained for investment

Strategy Decision (delete as appropriate)

Income Alpha Plus

Second Applicant

First Applicant

1 Account Name

Account Name

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

2 Applicant Details

Surname Forename(s)

Trust Name

Company Name

Title

Surname Forename(s) Title

5 Source of Wealth

Business Profits

Life Savings

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:

Salary/Bonus

Business Share/Sale

House/Property Sale

Pension Settlement

Inheritance

Other

Description Details Amount / Value

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

4 Source of Funds

Account Reference (for internal use only)

6 Declaration & Signature You must sign and date the form below

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.

Please ensure all fields are completed to avoid delays in processing © Capital International Limited 2011 Page 3

Signatures of ALL Applicants

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

PLEASE SIGN HERE

M M 2 0 Y Y D

Date

D Print Name

First Signature

PLEASE SIGN HERE

M M 2 0 Y Y D

Date

D Print Name

Second Signature

Delete as appropriate - Signing Together / Signing Alone _______________________________ Please indicate who Signing Authority (Joint Accounts)

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.

Registered Address

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

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

I am/am not registered for VAT:

Please tick the relevant commission structure:

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

Intermediary Stamp/Details:

X X X A B C D Other: .

7 Intermediary Details

Intermediary Name

Contact Name

Telephone Number

E-mail Address

Postcode

Firm Ref No

Y Y 0 2 M M D D

Acknowledged By:

Y Y 0 2 M M D D

Acknowledged By:

Y Y 0 2 M M D D

Acknowledged By:

Internal Use Only Received Date: Application Processed: Client Notification Sent:

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