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CLIENT INFORMATION SHEET

DATE: dd/mm/2018

TO: MONETIZER
REFERENCE: Client Information Sheet
TRANSACTION
CODE:
SECURITY CODE

IN ACCORDANCE WITH ARTICLES 2 AND 5 OF THE DUE DILIGENCE AND FEDERAL

BANKING COMMISSION CIRCULAR OF DECEMBER 1999, CONCERNING THE
PREVENTION OF MONEY LAUNDERING AS GOVERNED BY AND CONSTRUED IN
ACCORDANCE WITH THE LAWS OF ENGLAND AND WALES, THE FOLLOWING
INFORMATION MAY BE SUPPLIED TO BANKS AND TO FINANCIAL INSTITUTIONS FOR
PURPOSES OF VERIFICATION OF IDENTITY AND ACTIVITIES OF THE INVESTING
MEMBER, AND THE NATURE AND ORIGIN OF THE FUNDS WHICH ARE TO BE
UTILIZED.

AMOUNT OF FUNDS AVAILABLE:

NAME OF FUNDS BENEFICIAL
OWNER:

PERSONAL DATA
CLIENT NAME (SIGNATORY):
PASSPORT NUMBER:
COUNTRY OF RESIDENCE:
PASSPORT ISSUE / (DATE/PLACE):
PASSPORT EXPIRY DATE:
DATE AND PLACE OF BIRTH:
HOME ADDRESS (ADDRESS, CITY,
STATE, COUNTRY, POSTAL CODE)

HOME TELEPHONE NUMBER:

HOME FAX NUMBER:
MOBILE TELEPHONE NUMBER:
PERSONAL E-MAIL ADDRESS:
DO YOU SPEAK ENGLISH?
ARE YOU ABLE TO TRAVEL? (YES
OR NO)

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IF NO, PLEASE EXPLAIN REASON:

IF YES, ARE THERE ANY TRAVEL
RESTRICTIONS? (Please explain)
COMPANY DATA
COMPANY NAME:
COMPANY LEGAL ADDRESS
(ADDRESS, CITY, STATE,
COUNTRY, POSTAL CODE)
COMPANY MAILING ADDRESS
(ADDRESS, CITY, STATE,
COUNTRY, POSTAL CODE)
REGISTERED OFFICE DOMICILE:
TYPE OF COMPANY
REGISTRATION:
COUNTRY / STATE OF
REGISTRATION:
COMPANY REGISTRATION
NUMBER:
YEARS IN BUSINESS:
COMPANY TAX I.D. NUMBER:
COMPANY TELEPHONE:
COMPANY FAX:
COMPANY E-MAIL ADDRESS:
COMPANY INTERNET WEBSITE
ADDRESS:
LEGAL DATA:
LAW FIRM NAME: .
LEGAL ADVISER NAME:
LEGAL ADVISER MAILING
ADDRESS (ADDRESS, CITY,
STATE, COUNTRY, POSTAL CODE):
LEGAL ADVISER ADDRESS FOR
MAIL DELIVERY (ADDRESS, CITY,
STATE, COUNTRY, POSTAL CODE):
LEGAL ADVISER ADDRESS FOR
COURIER DELIVERY (ADDRESS,
CITY, STATE, COUNTRY, POSTAL
CODE):
BANK DATA:

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BANK NAME:
BANK BRANCH:
BANK ADDRESS (ADDRESS, CITY,
STATE, COUNTRY, POSTAL CODE):
BANK OFFICER / TITLE:
BANK OFFICER / TITLE.
BANK TELEPHONE NUMBER:
BANK FACSIMILE NUMBER:
BANK ACCOUNT NAME:
BANK ACCOUNT NUMBER:
BANK ACCOUNT SIGNATORY(S):
BANK ACCOUNT IBAN NUMBER:
BANK SWIFT CODE:
CLIENT’S ACCOUNT WHERE PROFITS ARE TO BE PAID:
BANK NAME:
BANK BRANCH:
BANK ADDRESS (ADDRESS, CITY,
STATE, COUNTRY, POSTAL CODE):

BANK ACCOUNT NAME:

BANK ACCOUNT NUMBER:
BANK ACCOUNT SIGNATORY(S):
BANK ACCOUNT IBAN NUMBER:
BANK SWIFT CODE:
FUNDS INFORMATION:
HOW WERE FUNDS EARNED?
ORIGIN OF FUNDS:
ARE FUNDS THE RESULTS OF MY
BUSINESS RELATIONS? (YES/NO)
ARE FUNDS FREE AND CLEAR?
(YES/NO)
BRIEF OVERVIEW OF CORPORATE
ACTIVITY:
IN WHAT FORM AND AMOUNT
ARE THE FUNDS IN FOR THIS
PRIVATE TRANSACTION?
(indicated if cash or bank
instrument and provide

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description)

I, ........................, WITH FULL AUTHORITY, HEREBY SWEAR UNDER PENALTY OF

PERJURY THAT THE INFORMATION GIVEN ABOVE IS BOTH TRUE AND ACCURATE. ALL
MONIES ENGAGED IN THIS TRANSACTION ARE DERIVED FROM NON-CRIMINAL
ORIGIN, AND ARE GOOD AND CLEAR. THE ORIGIN OF FUNDS IS IN COMPLIANCE
WITH ANTI-MONEY-LAUNDERING POLICIES AS SET FORTH BY THE FINANCIAL ACTION
TASK FORCE (FATF) 6/01.

Sincerely,

For and on Behalf of: Company Seal

Passport No:
Country of Issue:
Issue Date:

Confirmed by

For and on Behalf of:

Passport No:
Country of Issue:

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Copy of proof of funds

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AUTHORIZATION TO VERIFY AND AUTHENTICATE

DATE: dd/mm/2018
TO: Program Manager
REFERENCE: Authorization to Verify and Authenticate
TRANSACTION
CODE:
SECURITY CODE

Dear Sir,
I, …........................., holder of …................Passport No…....................., with full
corporate/ personal responsibility and under penalty of perjury, authorize the
supplier entity to verify the availability of our bank capability through a banking
institution or their representatives.

TYPE OF ASSETS:
NAME OF BANK:
BANK ADDRESS:
BANK SWIFT
CODE:
BANK
TELEPHONE:
BANK FAX:
BANK OFFICER
NAME:
ACOUNT NUMBER:
BANK ACCOUNT
NAME:

Signed facsimile and emailed copies of this Authorization to verify Bank Capability
shall be construed equal to the original and deemed legal and binding.
IN WITNESS WHEREOF, I have hereunder subscribed my name to this
Authorization to verify Bank Capability as the Investor on this day of…........., 2018

Sincerely,

For and on Behalf of: Company Seal

Passport No:
Country of Issue:

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Confirmed by

Passport No:
Country of Issue:

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Copy of passport

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