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DIVIDEND REINVESTMENT AUTHORIZATION
PLEASE NOTE: Dividend reinvestment is available on margin eligible securities. Generally, this includes 
all U.S. listed stocks, including Nasdaq issues valued at greater than or equal to $4.00 a share.
Select ONE of the following options:
Option 1
 Check this box to reinvest dividends on all eligible securities in your brokerage account.
• The account must contain at least one security to have the entire account coded for dividend
reinvestment.
Option 2
Complete the section below to reinvest dividends on selected securities only held in your account. Check 
the delete box to discontinue dividend reinvestment.
• Mark an "X" in either the Add or Delete column.
69257R   06-2007
ACCOUNT NAME
DATE
#
Add
Delete
NO Fractions
Security Name
Cusip #/ Symbol/ ADP #
CORRESPONDENT FIRM NAME
SUBMITTED BY
PHONE #
Fax this completed form to (866) 283-6097 or call (888) 859-9826.
Please type or print clearly in BLUE or BLACK ink.
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ACCOUNT NUMBER
Ridge Clearing & 
Outsourcing Solutions
