Sucursala/ Branch: CUI: Data/ Date: Operator de date cu nr./ Data operator no.: 1547 Nr.Reg.

Com:

CERERE DE DESCHIDERE CONT CURENT - PERSOANE JURIDICE

ACCOUNT OPENING APPLICATION - LEGAL ENTITIES Rezidenta/ Residence: Capital Social/ Registered Capital: Forma de proprietate/ Ownership: Detalii client/ Client details Client Rezident/Resident Autohton/Local Privat/Private Client Nerezident/Non-resident Mixt/Mixed Mixt/Mixed Strain/Foreign Stat/State

Denumire Titular cont/ Account holder name: Nr. Registrul Comertului/Trade Register No.: Capital social/Share capital: Adresa sediu social/Address of registered office: Nr./No.: Judet/County: Telefon/ Phone: Tara/Country: Fax: Cod CAEN: Bl.: Sc./Ent. Tara/Country: Web: Strada/Street: Ap./App.: Localitate/City: Sector/District: E-mail: Obiect activitate/Object of activity: CUI/Fiscal code: Moneda/Ccy

Adresa sediu central/ Address of headquarters: Adresa de corespondenta/ Mailing address*: Forma de Organizare/Organization Form Societate comerciala cu raspundere limitata sau pe actiuni/Limited or share Company Regie autonoma/Regies autonomes Reprezentanta/Representative office Persoana fizica autorizata/Free lancer Alte Informatii/Additional information Actionari Off-shore/Off-shore shareholders Solicitare client/ Client's request: Subsemnata, reprezentata legal prin: si prin: solicit deschiderea urmatoarelor conturi: RON EUR USD Se va completa de catre Banca/ To be filled in by the Bank: The undersigned, dully represented by: and by: I request the opening of the following accounts: RO BSEA RO RO RO RO RO BSEA BSEA BSEA BSEA BSEA Fundatie/Foundation Persoana juridica non-profit/Non-profit company Altele/Others: Companie Off-shore/Off-shore company Companie cu actiuni la purtator/Bearer shares company

IBAN: IBAN: IBAN: IBAN: IBAN: IBAN:

Declaratie Sursa Fondurilor/Source Funds Statement* Subsemnatul .., declar pe proprie raspundere, sub sanctiunea legii, ca sursa fondurilor la momentul deschiderii contului si pe parcursul relatiei cu banca, este si va fi: The undersigned , I declare in full responsibility and under the law provisions, that the source of funds at the account opening date and during the relation with the bank, is and will be:

*Declaratie in conformitate cu Regulamentul BNR nr. 9/2008 privind "Cunoasterea clientelei in scopul prevenirii spalarii banilor si finantarii terorismului" / Statement as per NBR Regulation no. 9/2008 on the KYC standards
EMPORIKI BANK ROMANIA S.A. Str.Berzei 19, Sector 1, Bucuresti, Romania + 40 21 310.3955, + 40 21 315.9783; + 40 21 310.3991 bank@emporiki.ro; http://www.emporiki.ro Capital Social: 196.089.737,27 RON

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Cod unic de inregistrare: 8490099 Reg. Comertului Nr. J40/3797/1996 Registrul Bancar Nr. RB-PJR-40-033/1999

Declaratie Beneficiar Real/Real Beneficiary Owner Statement* Subsemnatul declar pe propria raspundere, sub sanctiunea legii ca beneficiarul(ii) real(i) este/sunt (nume,prenume): The undersigned, I hereby state in full responsibility, under the law provisions that the real beneficiary(ies) is/are (name, surname):

Alte declaratii/Other Statements Subsemnatul .., in calitate de reprezentant legal al .............................., declar ca am luat cunostinta de prevederile Conditiilor Generale de Afaceri ale Bancii, cu care declar ca sunt de acord. Prin semnarea prezentei, confirm ca am primit un exemplar al Conditiilor Generale de Afaceri ale Bancii si imi asum raspunderea pentru realitatea si corectitudinea datelor si informatiilor furnizate in prezentul formular. Subsemnatul, ma oblig sa comunic bancii orice modificare referitoare la cele declarate mai sus. Banca isi rezerva dreptul de a refuza efectuarea tranzactiilor ordonate de client/de a inceta relatiile cu Clientul in cazul unor declaratii false sau daca are suspiciuni cu privire la realitatea celor declarate de catre Client. Servicii suplimentare/ Additional services Obtinerea de informatii prin telefon la Call Center/ Obtaining informations by phone via Call Center/ Branch Sucursala, privind soldurile conturilor dvs.si tranzactiile relating to your account balance and your transactions. efectuate pe acestea. Parola cont/ Account password** Semnaturi/ Signatures Titular de cont Banca Representanti legali / Legal representatives : Nume/Name: Semnatura: Aprobat de/ Approved by: Nume/Name: Director Sucursala / Branch Manager Semnatura /Signature: Nume/Name: Functie/Position: Semnatura /Signature: Stampila/Stamp The undersigned ., as legal representative of .................................., I hereby state to have acknowledge the stipulations of the Bank's General Business Conditions, to wich I agree. By signing the hereby statement, I confirm to have received a copy of the Bank's General Business Conditions and I am liable for the truthfulness and correctness of data and information provided hereby. I am hereby liable for submitting the bank any ammendment to the above. The Bank reserves the right to refuse performing the transactions ordered by the Client/to terminate the relations with the Client in case of false statements or in case there are suspicions on the truthfulness of the Client statements.

Nume/Name: Semnatura: Stampila/Stamp

*Declaratie in conformitate cu Regulamentul BNR nr. 9/2008 privind "Cunoasterea clientelei in scopul prevenirii spalarii banilor si finantarii terorismului" / Statement as per NBR Regulation no. 9/2008 on the KYC standards ** Parola poate contine: litere, cifre, caractere speciale. The password can contain: letters, numbers, simbols.
EMPORIKI BANK ROMANIA S.A. Str.Berzei 19, Sector 1, Bucuresti, Romania + 40 21 310.3955, + 40 21 315.9783; + 40 21 310.3991 bank@emporiki.ro; http://www.emporiki.ro Capital Social: 196.089.737,27 RON

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Cod unic de inregistrare: 8490099 Reg. Comertului Nr. J40/3797/1996 Registrul Bancar Nr. RB-PJR-40-033/1999