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3) Legal Counsel :
Address :
Telephone :
Facsimile :
E-Mail Address :
4) Funds Information
Funds available for 1st tranche :
Origin of Funds :
Are Funds clean and clear? :
6) Banking Details
Bank Name :
Address :
Telephone / Fax :
Bank Officers Name :l
Declaration: We hereby swear under penalty of perjury, that the information provided is both true and accurate. We
are the signatories on the aforementioned bank account. All monies engaged in this transaction are derived from
non-criminal origin; and, are good, clean and cleared. The origin of funds is in compliance with Anti-Money-
Laundering Policies as set forth by the Financial Action task Force (FATF) 6/01.
_________________________________
Signature
Name:
Title:
Passport #:
Country of Issue:
Date of Issue:
Date of Expiry:
PASSPORT COPY