CUSTOMER DUE DILIGENCE FORM – INDIVIDUAL CLIENT

A. PERSONAL DETAILS

Title: □ Mr □ Mrs □ Miss □ Minor □ Other Please specify

Surname Forename(s)

Spouse Full Name (if applicable) Maiden Name (if applicable)

Permanent Residential Address National Identity Card No.

(No P.O Box please)

…………………………………………
………………………………………… Date of Birth
…………………………………………
…………………………………………
………………………………………… Nationality

Passport No. (if applicable)

Telephone No.

Email Address (H)

(M)
(H) (O)
(O)

B. EMPLOYMENT DETAILS

Employment Status: □ Employed □ Retired □ Self-Employed □ Unemployed □ Housewife

Job Title Employer’s / Business Address if Self-Employed

…………………………………………
Employer’s Name …………………………………………
…………………………………………
…………………………………………
…………………………………………
If Self-Employed, please state nature of business

Source of Funds

□ Salary □ Savings from Income □ Inheritance □ Maturing Investments

□ Pension □ Rental/Property Sale □ Loan □ Sale of Shares

□ Lottery/Betting □ Dividends/Interests □ Gift □ Others (Please Specify)

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Average monthly income (MUR)

□ Less than 25,000 □ 25,000 to 50,000 □ Above 50,000

CLIENT DECLARATION

I, the undersigned, hereby declare that the information provided in this form and documents provided are true and
accurate at the time the transaction with Swan General Ltd and I hereby undertake to inform Swan General Ltd of
any change in the information contained herein.
I further declare that any transaction with Swan General Ltd, to which I am subscribing, is not connected to
money laundering or any other illegal activity either directly or indirectly.

_______________________________________ ____________________________________
Signature of Applicant Date

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