KNOW YOUR CLIENT (KYC) FORM STRICTLY PRIVATE & CONFIDENTIAL In accordance with Switzerland’s Due Diligence Convention and the Federal Banking Commission Circular of December 1998, and under the US Patriot Act of 2002, as amended in February 2003 concerning the Prevention of Money Laundering and 305 of the Swiss Criminal Code. The following information may be supplied to banks and/or other financial institutions for purposes of verification of Identity and activities of the Client described below, and the nature and original of the funds which are to be utilized. The foregoing is subject to agreement by all parties to whom this client and all individuals described herein, as well as the generally accepted professional standards relating to the maintenance of confidential information, and to take all appropriate precautions to protect the confidentiality of the information contained herein, this legal obligation shall remain in full force indefinitely without restriction. COMPANY INFORMATION Company Name: Company Number: Formation Date: Registered Address: City, State: Country: Postal Code: Work Telephone No.: Direct Number: Email Address: MEMBER INFORMATION First Name: Middle Name: Last Name: Gender: Select Male Female Date of Birth: Country of Citizenship: Passport Number: Date of Issue: Date of Expiry: Country of Issuance: Home Street Address: City, State: Postal Code Country of Residence: LANGUAGES Languages Spoken: English Fluent? Select Yes No If you have selected "NO", please provide your translator's information. Transator Full Name: Translator Phone: Translator Email: LEGAL ADVISORS Company Name: Company Address: Area: City: Country: Postal Code: Work Telephone No.: Direct Number: Email Address: BANK INFORMATION BANK NAME: BIC/SWIFT Code: Street Address: City: Country Postal Code: Clearing House ID: Account Name: Account Number: Further Credit to: Account Signatory: Bank Officer: Bank Telephone: Bank Fax Number: Bank Email: ACKNOWLEDGEMENT I, the Signatory of this KYC Form, hereby swear under penalty of perjury, that all data provided herein does not contain intentionally false, misleading, or material misrepresentations attempting the concealment of facts; all information provided herein is factual, accurate and true as per the date of this document. By checking this box you authorize the above statement. Authorization Date: Printed Name: Company Title: Passport#: Issue Date: Expiry Date: Issue Country: MEMBER PASSPORT Please Upload Copy of Passport CORPORATE REGISTRATION Please Upload Corporate Registration submit
