(COMPANY LETTER HEAD)
CLIENT INFORMATION SHEET
The following information is necessary for the due diligence process and compliance
with standard international banking regulations and treaties. All information is
treated in the strictest privacy and confidence. To ensure that any application and
due process is conducted efficiently and correctly, it is important that the following
information is accurate and true.
1. Client Name (Signatory):
2. Account Name Owner / Beneficiary:
3. Passport Number:
4. Country of Residence:
5. Passport Issue / (Date/Place):
6. Passport Expiry Date :
7. Date and Place of Birth :
8. Verifiable Home Address :
9. Home Telephone Number :
10. Home Fax Number :
11. Mobile Tel Number :
12. Business Telephone Number :
13. Business Fax Number :
14. Clients Email Address
15. Address for Mail Delivery
16. Do you speak English or need assistance?
17. Occupation / Line of Business
18. Legal Adviser: (Law Firm)
19. Legal Adviser Mail Address :
20. Bank Name
21. Branch Office Address
22. Bank Officer / Title
23. PHONE & FAX
24. SWIFT Code
25. Account Name
26. Account Number
27. Account Signatory
FUNDS / ASSET AVAILABLE FOR DEPOSIT:
28. Origin of Funds? How were Funds earned?
29. Brief Overview of Corporate Activity /
Employment
30. Are the funds free and clear of commitment,
encumbrances, liens and they are not on loan?
INITIALS: ………….. INITIALS: …………..
(COMPANY LETTER HEAD)
DECLARATION: I/we declare that the information given above is both true and accurate. I am the
signatory on the aforementioned bank account / owner of bank instrument. I confirm and declare that my
funds are good, clean, and clear and of non-criminal origin and that said funds have been earned in the
course of normal commercial business and are of commercial origin and legally generated and the funds and
assets involved, are not in breach of the “Money Laundering Regulation/Accord of 1993,” howsoever
interpreted and defined, whether within the host state of the transaction or internationally. I further declare
that there are no liens, commercial obligations or encumbrances of any kind afflicting or touching said funds
and that there are no other currently valid or pending commitments.
NON-SOLICITATION: I hereby declare that I am fully aware that the information presented by you is not in
any way considered or intended to be solicitation of funds of any sort, or any type of offering, but is intended
for general knowledge and educational purposes only. I affirm that I have requested information from you
and your associates of my own choice and free will, and further that you have not solicited me in any way.
All parties have an obligation to respect professional secrecy and to take all appropriate precautions to
protect the confidentiality of the information each holds in respect of the others’ activities. This legal
obligation shall remain in full force and effect at all times.
DATE: …………………….. 2016
SIGNATURE…………………………………...................
Name:
WITNESS………………………………………......................
Name:
Address:
Phone:
INITIALS: ………….. INITIALS: …………..
(COMPANY LETTER HEAD)
PASSPORT COPY
INITIALS: ………….. INITIALS: …………..
