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Client information sheet june 2016

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1. [INSERT APPLICANT LETTERHEAD IN HEADER SPACE] APPLICANT INITIALS ___________ PAGE 1 OF 5 CLIENT INFORMATION SHEET DIRECTIONS: THIS DOCUMENT SHOULD BE COMPLETED IN…
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  • 1. [INSERT APPLICANT LETTERHEAD IN HEADER SPACE] APPLICANT INITIALS ___________ PAGE 1 OF 5 CLIENT INFORMATION SHEET DIRECTIONS: THIS DOCUMENT SHOULD BE COMPLETED IN FULL. IF A LINE ITEM DOES NOT PERTAIN THEN INSERT THE TERM: “N/A” (NON-APPLICABLE). CORPORATE INFORMATION (IF APPLICABLE) FULL NAME OF CORPORATION: DATE OF INCORPORATION: INCORPORATED IN (CITY/STATE/COUNTRY): REGISTRATION NUMBER: BOARD OF DIRECTORS (NAME & TITLE): OFFICERS (NAME & TITLE): SHAREHOLDERS: PERSONAL INFORMATION OF PRINCIPAL SIGNATORY FIRST NAME: MIDDLE NAME: LAST NAME: GENDER: DATE OF BIRTH: SOCIAL SECURITY NUMBER: COUNTRY OF CITIZENSHIP: LANGUAGES: PASSPORT NUMBER: DATE OF ISSUE: DATE OF EXPIRY: ISSUING AUTHORITY: REGISTERED ADDRESS (FOR CORPORATION ONLY) STREET ADDRESS: CITY: STATE: COUNTRY: POSTAL CODE:
  • 2. [INSERT APPLICANT LETTERHEAD IN HEADER SPACE] APPLICANT INITIALS ___________ PAGE 2 OF 5 LOCATION OF ADDRESS: LIVING OR MAILING ADDRESS STREET ADDRESS: CITY: STATE: COUNTRY: POSTAL CODE: CONTACT INFORMATION TELEPHONE NUMBER: FAX NUMBER: MOBILE NUMBER: EMAIL ADDRESS: SKYPE: LANGUAGES / TRANSLATOR LANGUAGES: DOES THE SIGNATORY SPEAK ENGLISH?: IF NO, NAME OF TRANSLATOR: TEL NUMBER: EMAIL ADDRESS: LEGAL ADVISOR FULL NAME: COMPANY: ADDRESS: CITY: STATE: COUNTRY: POSTAL CODE: TELEPHONE NUMBER: FAX NUMBER: EMAIL ADDRESS:
  • 3. [INSERT APPLICANT LETTERHEAD IN HEADER SPACE] APPLICANT INITIALS ___________ PAGE 3 OF 5 BANK INFORMATION BANK NAME (WHERE FUNDS ARE CURRENTLY ON DEPOSIT): STREET ADDRESS: CITY: STATE: COUNTRY: POSTAL CODE: ACCOUNT NAME: ACCOUNT NUMBER: SORT CODE ABA NO.: SWIFT CODE: ACCOUNT SIGNATORY (1): ACCOUNT SIGNATORY (2): BANK OFFICER # 1 NAME: BANK OFFICER # 2 NAME: TELEPHONE NUMBER: FAX NUMBER: CLIENT ACCOUNT WHERE PROFITS TO BE PAID BANK NAME: STREET ADDRESS: CITY: STATE: COUNTRY: POSTAL CODE: ACCOUNT NAME: ACCOUNT NUMBER: SORT CODE ABA NO.: SWIFT CODE: BANK OFFICER NAME: TELEPHONE NUMBER: FAX NUMBER:
  • 4. [INSERT APPLICANT LETTERHEAD IN HEADER SPACE] APPLICANT INITIALS ___________ PAGE 4 OF 5 INVESTMENT FUNDS AVAILABLE FOR THIS TRANSACTION: TYPE OF CURRENCY: DETAILED ORIGIN OF FUNDS: ARE THESE FUNDS FREE AND CLEAR OF ALL LIENS, ENCUMBRANCES AND THIRD PARTY INTERESTS: I, (NAME), HEREBY SWEAR UNDER PENALTY OF PERJURY, THAT THE INFORMATION PROVIDED HEREIN IS ACCURATE AND TRUE AS OF THIS DATE: JUNE 5, 2016 FOR AND ON BEHALF OF (NAME OF COMPANY / INDIVIDUAL) SIGNATURE: __________________________________ SEAL OF COMPANY NAME / TITLE: COMPANY: PASSPORT NUMBER: DATE OF ISSUE: DATE OF EXPIRY: COUNTRY OF ISSUANCE:
  • 5. [INSERT APPLICANT LETTERHEAD IN HEADER SPACE] APPLICANT INITIALS ___________ PAGE 5 OF 5 COPY OF CLIENT’S PASSPORT
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