CLIENT INFORMATION SUMMARY
Undertakings have to be given to the Financial Institutions in order that everything may be in place to ensure proper execution of the obligations concerning verification of the identity of the contracting partner and identification of the beneficial owner as established in the articles 2 to 5 of the Due Diligence Convention, the Federal Banking Commission circular of December 1991 concerning the prevention of money laundering and article 305, the terms of the Swiss Criminal Code. When an Investor is introduced, undertakings have to be given to the Financial Institutions to supply all the information concerning the Investor’s identification and activities and the nature and origin of the funds, which are to be deposited with the Financial Institution. All parties are obligated to respect professional secrecy and take all appropriate precautions to protect the confidentiality of the information in holds in respect to their activities. Each party has a legal obligation to respect professional secrecy, which shall remain in force at all times.
Please complete where applicable (if handwritten: in black Ink and capital Letters):
PERSONAL
Client Signatory Name :
Address :
Nationality :
Business Telephone Number :
Home Telephone Number :
Mobile Telephone Number : +
E-Mail (confidential) :
Passport Country of Issue :
Passport Number :
Date of Issue :
Expiration Date :
Date of Birth :
Place of Birth :
BUSINESS
Company Name (if appropriate) :
Company Address :
Domicile & Registration No :
Description of Corporate Activity :
LOCATION OF ASSET
Current Bank Name :
Bank Address :
Bank Officer :
Telephone Number : +
Facsimile : +
Bank Officer e-mail address :
Account Holder :
Account Number :
IBA Number :
Swift Code :
Cash Funds Available :
Duration of Funds in Possession :
Currency :
Status of Funds :
ACCOUNT FOR DEPOSIT
Current Bank Name :
Bank Address :
Bank Officer :
Telephone Number : +
Facsimile : +
Bank Officer e-mail address :
Account Holder :
Account Number :
IBA Number :
Swift Code :
Account Currency ………………….. .:
Source of Origin/History of Investment Funds :
Are Funds/Instruments free of Liens or Encumbrances: Yes / No
Have Funds/Instruments been offered previously for a Private Transaction: Yes / No
If so when :
With whom :
Any special Information/notes (i.e. do you need a translator?) :
Acknowledgement & Attestation
I hereby confirm verify and attest hereto, that the above named Authorised Signatory is the true owner of the funds and that I am the sole signatory on the Bank Account, and have full and absolute authority to execute all of the contracts and agreements relating to the Private Placement Investment Program, and that I fully understand all future communication will be directly between the Private Placement Investment Program Manager and the undersigned with no intermediary involvement.
I hereby verify and affirm that the above statements are true and correct to the best of my knowledge and belief.
Signed this ..th day of ….. 2014
______
Signature:
Name & Title: (Print)
For and on behalf of (if appropriate)
Passport Number:
Country of Issue:
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