CLIENT (BENEFICIARY) INFORMATION SHEET

NB In accordance with Articles two (2) through five (5) of the Due Diligence Convention and the Federal
Marketing Commission Circular of December 1998, concerning the prevention of money laundering,
the following information may be supplied to banks and/or other Federal Institutions for purposes of
verification.
1 Date :
2 Client Name (Signatory) : First Name:
Middle Name:
Last Name:
3 Residence :
4 Passport Number :
5 Passport Issue /Expire Date : Date of Issue:
Date of Expiry:
6 Federal ID Number :
7 Date of Birth /Date :
8 Home Address :
9 Cellular Phone Number :
10 E-mail Address :
11 Skype ID :

12 Business Name :
13 Business Address :
14 Registered Office :
15 Registration Number :
16 Business Fax Number :
17 Business Phone Number :
18 E-mail Address :

19 BANK NAME :
20 Bank Address :
21 Bank Officer’s Name :
22 Bank Officer’s PIN
23 Telephone Number(s) :
24 Fax Number :
25 Bank Officer E-mail :
26 Account Name :
27 Account Signatory Name :
28 Account Number :
29 SWIFT Code :

30 Lawyer Name :
31 Lawyer´s E-mail :
32 Lawyer´s Address :
                  
 Signature Seal