Customer Type:

Full Name (Legal name as per official documents)*:

Legal Type: Private Joint Stock Company Public Joint Stock Company Partnership Limited Liability Company Company Limited by Shares Limited Partnership Company Foreign Operating Company Foreign Non-Operating Company Other

Registration No.:

Date of Incorporation:

Expiry Date (if any):

License No. (if any):

Issuance Date of Profession License:

Expiry Date (if any):

Regulator/ Issuing Body:

Country of Residence:

Country of Incorporation:

Website:

Nature of Business:

TIN Number:

BANKING DETAILS*

DECLARATION OF BENEFICIAL OWNERSHIP*

The Company hereby confirms and declares that as at date hereby, the following individual(s) is/are the ultimate principal beneficial owner(s) of the Company through ownership in the intermediate or ultimate holding companies:

Add Beneficial Owner

Full Name	Detailed Residential Address (Area, Street, Bldg, Floor, Country)	Date and Place of Birth	Nationality	Percentage of Ownership (%)

Please note that a Separate Individual KYC Form must be signed by each UBO

SHAREHOLDERS

The Company hereby confirms and declares that as at date hereby, the following individual(s) is/are the Shareholder(s) of the Company through ownership in the intermediate or ultimate holding companies:

Add Shareholder

Full Name	Detailed Residential Address (Area, Street, Bldg, Floor, Country)	Date and Place of Birth	Nationality	Percentage of Ownership (%)

Please note that a Separate Individual KYC Form must be signed by each Shareholder.

DIRECTORS

The Company hereby confirms and declares that as at date hereby, the following individual(s) is/are the Director(s) of the Company:

Add Director

Full Name	Detailed Residential Address (Area, Street, Bldg, Floor, Country)	Date and Place of Birth	Nationality

Please note that a Separate Individual KYC Form must be signed by each Director

AUTHORIZED SIGNATORY(IES)

The Company hereby confirms and declares that as at date hereby, the following individual(s) is/are the Signatory(s) of the Company:

Add Authorized Signatory

Full Name	Detailed Residential Address (Area, Street, Bldg, Floor, Country)	Date and Place of Birth	Nationality

Please note that a Separate Individual KYC Form must be signed by each Signatory at the Company.

Company:

Sources of Income

Sources of Wealth*

*Source of Wealth describes how a client, or their family, has acquired their total wealth.

DECLARATION

I hereby declare that the details provided above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misrepresenting, I am aware that I may be liable for it.