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CUSTOMER INFORMATION SHEET – PRIVATE PERSON

Personal data collected through this Questionnaire will be processed for the purpose of customer due dilligence, in accordance with the Law on the Prevention of Money Laundering and the Financing of Terrorism and referent regulations.

Note:This Questionnaire may be fulfilled only by the Account Holder in person, while the Authorized Person (if any) shall complete other type of the questionnaire.

First name,Last name:______

Personal ID Number:______Date of birth: ______

Place of birth: ______Country of birth: ______

Citizenship: ______Sex: ______

Residence (from the ID Document):

  • Address: ______
  • Town: ______

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  • Postal code: ______
  • Country: ______

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Domicile (if different from residence):

  • Address: ______
  • Town: ______

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  • Postal code: ______
  • Country: ______

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ID Document:

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  • Type: ______
  • Number: ______
  • Issuer: ______
  • Date of release: ______

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Activity:

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  • Employee
  • Entrepreneur
  • Freelancer
  • Self-employed
  • Unemployed
  • Student
  • Retired
  • Other

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Additional information:

Have you or your close relative held at any time during last 12 months a public office, or have you been close associate of such person:

  • In Serbia:YESNO
  • In a foreign country or international organization: YESNO

Country where the main business is carried out: ______

Type of transactions that will be processed through the account:

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  • Cash transactions
  • Cross-border transactions
  • Wire transactions
  • Savings and investments

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  • Other: ______

Will the turnover on the account mostly refer to cash transactions? If YES, please explain the reasons and specify the expected average amounts (roughly):

______

Please specify the expected average level of in-payments to the account:

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  • Up to 1,000 Euros monthly
  • Up to 2,000 Euros monthly
  • Up to 4,000 Euros monthly
  • Up to 10,000 Euros monthly
  • Over 10,000 Euros monthly

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What are the expected sources of funds:

  • Regular salary
  • Other (please specify): ______

Annual amount of expected other income:______

Will the Customer carry out transactions on behalf of third persons through the account?YESNO

Hereby I confirm that all data given in this document are true and I am in full agreement with the Bank's right to check them. I will promptly inform the Bank on any change regarding the data given above.

Hereby I confirm that the bank has informed me of the following:

  • That processing of the personal data contained in this questionnaire is based on the law;
  • My rights and obligations of the Bank in connection with the processing of the personal data – by insight to "Notification on the conditions of collection and processing of personal data" and evidence in register collection named "Database on basic data of natural persons for all Bank products - No.1";
  • The possibility to check the details on mentioned processing of data in the Central Data File Register maintained by the Commissioner for Information of Public Importance and Personal Data Protection, available at Web address: , in collection named "Database on basic data of natural persons for all Bank products - No.1 ".

______, ______

PlaceDateSignature

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