COMPANY INFORMATION SHEET (CIS) FORM

Issued To: WTC & Orbis Mercatus B.V Ref CIS Number: WTC-CIS/0420
Attention: Mr. Kurt Johann Kaiser
Mr. Farhan Omer

Dear Sir/Madam,
SUBJECT: COMPANY INFORMATION SHEET (CIS)
In accordance with Articles Two (2) through Five (5) of the Due Diligence Convention and the Federal
BANKING 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.

Personal Information
First Name:
Middle Name:
Last Name:
Gender:
Date of Birth:
Social Security Number:
Country of Citizenship:
Passport Number:
Date of Issue:
Date of Expiry:
Issuing Authority:
Home Street Address:
City:
State:
Country:
Postal Code:
Telephone Number:
Fax Number:
Mobile Number:
Email Address:

Corporate Information
Full Name of Corporation:
Date of Incorporation:
Incorporated in (City/State/Country):
Registration Number:
Board of Directors (Name & Title):
Officers (Name & Title):
 Shareholders (List all shareholders owning
more than 5 % of all outstanding shares of
Corporation):

Location of Address: Mailing Address (Corporation)

Full Name of Corporation:
Street Address:
City:
State:
Country:
Postal Code:

Contact Information (Corporation)

Telephone Number:
Fax Number:
Mobile Number:
Email Address:
Website:

Bank Information
Bank Name:
Street Address:
City:
State:
Country:
Postal Code:
Account Name:
Account Number:
Sort Code ABA No.:
SWIFT Code:
Account Signatory (1):
Account Signatory (2):
Bank Officer # 1 Name:
Bank Officer # 2 Name:
Telephone Number:
Fax Number:
Bank Officer: E-Mail Address:
Bank Website:
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