In accordance with Articles two (2) through five (5) of the Due Diligence Convention and the Federal

In accordance
Banking with Articles
Commission Circulartwoof(2) through 1998,
December five (5)concerning
of the DuetheDiligence Convention
prevention of moneyand the Federal
laundering, and
Banking305
Article Commission
of the SwissCircular
Criminalof December 1998, concerning
Code, the following the prevention
information of money
may be supplied laundering,
to banks and/orandother
Article 305
financial of the Swiss
institutions for Criminal
the purposeCode,of the following
verification ofinformation may be have
identity All parties supplied to banks and/or
an obligation other
to respect
financial institutions
professional secrecy for
andthe
to purpose of verification
take all appropriate of identitytoAllprotect
precautions partiesthe
have an obligation
confidentiality ofto
therespect
professionaleach
information secrecy and
holds in to take all
respect ofappropriate precautions
the others’ activities. to legal
This protect the confidentiality
obligation of in
shall remain thefull force
information each holds
and effect at all times. in respect of the others’ activities. This legal obligation shall remain in full force
and effect at all times.
B E N E F I CIARY/BORROWER/COMPANY
B E N E F I CIARY/BORROWER/COMPANY
Beneficiary/Borrower/Company
Beneficiary/Borrower/Company
Beneficiary/Borrower/Company
Borrower / Signatory Name
Borrower
Borrower
Nationality / Signatory
/ Signatory
NameName
Nationality
Driver License Number Nationality
DriverofLicense
Date DriverNumber
Issue License Number
Date
Date of
of Issue
Expiration Date of Issue
Date of Expiration
Country Date of Expiration
of Issue
Country
Date of Issue
of Birth Country of Issue
(MM/DD/YYYY)
Date
Date
Place ofofBirth
of Birth
Birth(MM/DD/YYYY)
(MM/DD/YYYY)
Place
Contact Address Place of Birth
of Birth
Contact Address
Passport Number Contact Address
Passport
Country ofNumber Passport Number
Residence
Country of Country
Date of Issue Residenceof Residence
Date of
Date of Expiration
Issue Date of Issue
Date of Expiration
Contact Date of Expiration
Telephone
Contact Telephone
Contact
Borrower E-mail Address Telephone
Borrower Borrower
E-mail Address
E-mail Address
B U S I N E SS INFORMA TION
B U S I N E SS INFORMA TION
Business Name
Business
Business Name
AddressBusiness Name
Business Address
Mailing AddressBusiness Address
Mailing Address
Registered OfficeMailing Address
Domicile
Registered
Registered
Country Office
/ State ofOffice
Domicile
Domicile
Incorporation
Country
Country // Telephone
Business State
State of
of Incorporation
Incorporation
Business Telephone
Business Telephone
1. Attach a copy of Drivers License (Official Government ID)
1.
2. Attach
Attach aa copy
copy of
of Drivers License Card
Social Security (Official Government ID)
2. Attach a copy of Social Security Card