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KYC
Title
Mr.
Ms.
Mrs.
Miss.
Other, (Specify)
Other
Last Name*
First Name*
Middle Name
Passport or Identity Card No.*
Country of Issue*
Expiry Date*
Telephone Number*
Fax Number
Email Address*
Country of Permanent Residence*
Nationality*
Date of Birth*
Place of Birth*
Gender*
Male
Female
Other
Marital Status*
Single
Married
Widowed
Divorced
Are you a United State resident for Tax purposes:
Yes
No
Are you a United States Citizen:
Yes
No
If Yes, please give details
Jurisdiction(s) for Tax purposes*:
Tax Identification Number (TIN)*:
Are you Politically Exposed or associated to any Political person:
Yes
No
If Yes, please give details
Occupation*
Employer's Name:
Employer's Business Address
Employer's Phone:
Employer's Website:
Permanent Physical Address*
Street Name & Number
Flat
Area
Postal Code
City
Country
Mailing Address (if different from the Permanent Address)
Street Name & Number
Flat
Area
Postal Code
City
Country
Telephone No.*
Home
Work
Mobile
Fax
E-mail Address*
Personal
Work
Preferred language of communication *
English
Other, Specify
Other
General Terms
1. 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.
2. 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 nonprompt amendment of data which I have omitted or neglected to send and to inform the company.
3. Know Your Client documentation
Please attach to this application form, where applicable, the following documents:
1- Color copy of Identity Card or Passport
2- Copy of a recent Utility bill (e.g. of electricity or telephone, or other document to the satisfaction of the Company evidencing the permanent residence of the Customer - 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
Upload all Files
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.
Customer Name:*
Signature:*
Date:*
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CLIENT AGREEMENT
CLIENT CATEGORIZATION POLICY
AML POLICY
TERMS AND CONDITIONS
