Register Individual - ASK Services Intl. LTD

1

Personal Information

First Name *

Middle Name

Last Name *

Passport or Identity Card No. *

Expiry Date *

Country of Issue *

Date of Birth *

Place of Birth *

Gender

Marital Status *

Nationality *

Country of Permanent Residence *

2

Contact Details

Phone Number *

Fax Number

Email Address *

Preferred Language of Communication *

English

Arabic

French

Other

Please specify

3

Taxable Residence

Are you a United States Resident for Tax purposes?

Yes

No

Are you a United States Citizen?

Yes

No

Please give details

Jurisdiction(s) for Tax Purposes *

Tax Identification Number (TIN) *

Are you Politically Exposed or associated to any Political Person?

Yes

No

Please give details

4

Occupation

Occupation *

Employer's Name

Employer's Phone

Employer's Business Address

Employer's Website

5

Permanent Physical Address *

Street Name & Number

Flat

Area

Postal Code

City

Country

6

Mailing Address (if different from Permanent)

Street Name & Number

Flat

Area

Postal Code

City

Country

7

Telephone Numbers *

Home

Work

Mobile

Fax

8

Email Addresses *

Personal

Work

9

General Terms & Declarations

I hereby confirm that the information given above is true, correct and complete and you are hereby authorized to use this information for all services offered and for which I may apply from time to time and for all the services offered in the future.
Change of data — For any changes in the data given above, I have the obligation to notify the company the soonest possible and I acknowledge that the company is not liable for any wrong data, or for the non-prompt amendment of data which I have omitted or neglected to send and to inform the company.

Know Your Client documentation — Please attach to this application form, where applicable, the following documents:

N	Policy name
1	Color copy of Identity Card or Passport
2	Copy of a recent Utility bill (e.g. electricity or telephone — maximum 6 months old)
3	Recent bank statement if applicable (maximum 6 months old)

*The above documents are not exhaustive and the Company may require additional documents where this shall be deemed necessary.

I hereby declare and confirm that these are true and correct and that I have not withheld any relevant or substantial information.

I confirm that I have delivered whatever is required in accordance with point 3 above and that such are original and authentic and content is true and accurate.

Client Name *

Date *

Signature (image file) Accepted: JPG, PNG, PDF

Color Copy of Identity Card or Passport *

Copy of a Recent Utility Bill

Recent Bank Statement (max 6 months old)

KYC Individual