Customer Information Form (Entity/Business)

B. Major Shareholder(s/Owner(s)) Details

(Representing 10% or more. Identification documents may be required)
No. of Shareholders/Owners

Shareholder/Owner 1
First NameLast Name
Shareholding %
Country
Identification Document 1

Cancelof
Identification Document 2

Cancelof

Shareholder/Owner 2
First NameLast Name
Shareholding %
Country
Identification Document 1

Cancelof
Identification Document 2

Cancelof

Shareholder/Owner 3
First NameLast Name
Shareholding %
Country
Identification Document 1

Cancelof
Identification Document 2

Cancelof

Shareholder/Owner 4
First NameLast Name
Shareholding %
Country
Identification Document 1

Cancelof
Identification Document 2

Cancelof

SHAREHOLDER/OWNER END

C. Authorized Signatures

Please provide information on beneficial owner(s). Identification documents may be required
No. Of Authorized Signatures
Signatory
Position
Signatory
Position
Signatory
Position
Signatory
Position

E. Directors &/or Company Secretary
No. of Directors

Director 1
Name

First NameLast Name
Residential Address:
Address Line 1
Address Line 2
City
State / Province
Postal / Zip Code
Place of Birth

Director 2
Name

First NameLast Name
Residential Address:
Address Line 1
Address Line 2
City
State / Province
Postal / Zip Code
Place of Birth

Director 3
Name

First NameLast Name
Residential Address:
Address Line 1
Address Line 2
City
State / Province
Postal / Zip Code
Place of Birth

Director 4
Name

First NameLast Name
Residential Address:
Address Line 1
Address Line 2
City
State / Province
Postal / Zip Code
Place of Birth

DIRECTOR END
Company Secretary
First NameLast Name
Residential Address:
Address Line 1
Address Line 2
City
State / Province
Postal / Zip Code
Current/Previous Occupation:
Tel. (H):
Please enter a valid phone number.
Tel. (W):
Please enter a valid phone number.
Place of Birth

F. Sanctioned Countries Declaration
On behalf of {name}, I hereby declare that the named entity is is not on any Sanctions List issued by any country.
Please state country and reason
Country
Reason
On behalf of {name}, I hereby declare that the named entity is is not related to or affiliated with any person, institution, business organization or any entity sanctioned by any country.
Please state country and reason
Country
Reason

G. Customer Declaration
On behalf of the owner/s of {name}, I, the undersigned hereby declare under penalty of perjury, that all information provided in support of this application is true and correct to the best of my knowledge and belief and confirm that the Bank is entitled to verify same directly or through any third party. I also agree that, if any such declaration made by me is found to be incorrect, the Bank is not bound to pay any interest on the account(s) and is entitled to terminate the account relationship. I confer authority on the Bank to disclose information and data relating to my account as part of relevant statutory and regulatory mandates on a confidential basis to any agency duly authorized by law, rule or regulation, or to market the Bank’s products and services, without any further consent or authorization from me.
{signatory}
MonthDayYear
Date
{signatory247}
MonthDayYear
Date
{signatory249}
MonthDayYear
Date
{signatory251}
MonthDayYear
Date

Bank Use Only
Loaded by:
Signature:
Date

MonthDayYear
Verified by:
Signature
Date

MonthDayYear
Loaded by:
Signature
Date

MonthDayYear
Notes:
Should be Empty: