DUE DILIGENCE QUESTIONNAIRE

1. GENERAL INFORMATION
Name of Legal Entity

Type of Client Public Company Trust/Foundation Private Company

Partnership/Unincorporated Business Public Sector/State Owned

Other:

Registered Address

Business/
Correspondence
Address
Name and Jurisdiction of Regulator
Regulatory Authority Unique ID
Date of Incorporation Country of Incorporation / Registered
/establishment establishment Company #
Tax Id Number Legal Entity Identifier
(LEI)
Nature of business

Website

2. Please indicate Board of Directors/Members or Legal representatives with significant responsibility for
managing the entity
Date of
Corporate Title Full Legal Name Country of Residence
Birth
Director
Director
Director
Director
Director
Is the company listed on the regulated YES NO Indicate Symbol__________
markets?

3. Please indicate the ultimate beneficial owners, who directly or indirectly owns over 10% of its shares or voting
rights of the entity. For companies listed on regulated markets, indicate 25% ownership of the remaining unlisted
shares
Full Legal Name: Date of Birth % of Ownership PEP

Residential Address Country Postal Code

Id number country of Source of

issuance wealth
Full Legal Name Date of Birth % of Ownership PEP

Residential Address Country Postal Code

Id number country of Source of

issuance wealth

Full Legal Name Date of Birth % of Ownership PEP

Residential Address Country Postal Code

Id number country of Source of

issuance wealth

Full Legal Name Date of Birth % of Ownership PEP

Residential Address Country Postal Code

Id number country of Source of

issuance wealth

Full Legal Name Date of Birth % of Ownership PEP

Residential Address Country Postal Code

Id number country of Source of

issuance wealth
4. Compliance/Onboarding/Back Office Contacts
Details of your Compliance /Onboarding
team correspondence details (e.g. Name,
Contact number, Email Address)
Details of your Back Office/Ops (e.g.
Name, Contact number, Email Address)
Crest Details
5. Type of Documents and Verification Provided (please indicate YES when copies of documents were provided to
complete the onboarding process)
Certificate of Incorporation Attached
Ownership Structure (e.g. a group Attached
organisational chart which shows the
percentage owned)
Articles and Memorandum of Association Attached
Share Register NA
Relevant Register Attached
Director’s Register Attached
UBO’s Passport (s) Attached
UBO’s Proof (s) of Address Attached
Director’s Passport (s) NA
Director’s Proof (s) of Address NA
Certificate of Trade NA
Trust Deed and Rules NA
Revenue Approval NA
Pension Board Approval NA
Evidence of Individuals authorised to NA
operate the trust/transfer fund
Partner’s Register NA
Partner’s Passport (s) NA
Partner’s Proof of Address NA
Authorised signatory list (certified) Attached
Authorised traders list NA
Last audited financial accounts Attached
MiFID Client Categorisation Letter Attached
Terms of Business Attached
Wolfsberg Questionnaire or relevant Attached
AML Policy
SSIs Attached
Other Any other relevant documents
6. U.S. Persons (please indicate Yes or No and provide W-8BEN-E form when answered Yes)
Does the client consist of US citizens or
US residents
Does the client consist of corporations or
partnerships created or organised in the
US
Accounts held by certain passive entities
with shareholders who are US citizens or
US residents (Refer to sec.gov definition)
7. Legal Proceedings
Does the company or any key employees or members of senior management, its
subsidiaries or affiliates have any pending litigation, regulatory investigations,
governmental actions, arbitrations, ```disputed accounts or other unresolved matters in
any country or territory?

Has the company ever been subject to Bankruptcy/Insolvency proceedings in any

country or territory?

8. CERTIFICATION SECTION

I _______________________________________ hereby certify, to the best of my knowledge, that the information provided
above is complete and correct. I agreed to notify xxxxxxxxxx promptly of any changes to this information. In case of any of
the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable
for it.
Please note, further KYC requirements may be requested.
Signature

Corporate Title Date