(ON CORPORATION’S LETTERHEAD TYPED IN 14 SIZE FONTWITH FULL

ADDRESS, PHONE (+_____) WITH EACH PAGE NUMBERED AND INITIALED.)

CLIENT INFORMATION SHEET (C.I.S.)

In accordance with Articles 2 through 5 of the Due Diligence Convention and the Federal Banking Commission
Circular of December 1998, and under the US Patriot Act of 2002, as amended in February 2003 concerning the
prevention of money laundering and 305 of the Swiss Criminal Code, the following information may be supplied to
banks and/or other financial institutions for purposes of verification of identity and activities of the Client described
below, and the nature and origin of the funds which are to be utilized. The foregoing is subject to agreement by all
parties to whom this information is provided that they are obligated to respect the privacy rights of the Client and all
individuals described herein, as well as the generally accepted professional standards relating to the maintenance of
confidential information, and to take all appropriate precautions to protect the confidentiality of the information
contained herein, This legal obligation shall remain in full force indefinitely without restriction.

1) Company Full Name :

Business Address :
Business Registration No. :
Telephone :
Facsimile :
E-Mail Address :

2) Signatory Full Name :

Title :
Nationality :
Passport No. :
Date of Issue :
Date of Expiration :
Date of Birth :
Place of Birth :
SSN/Identity No. :.
Address :
Telephone :
Mobile Telephone :
Facsimile :
E-Mail Address :

3) Legal Counsel :
Address :

DATE:diciembre 12, 2019

(ON CORPORATION’S LETTERHEAD TYPED IN 14 SIZE FONTWITH FULL
ADDRESS, PHONE (+_____) WITH EACH PAGE NUMBERED AND INITIALED.)

Telephone :
Facsimile :
E-Mail Address :

4) Funds Information
Funds available for 1st tranche :
Origin of Funds :
Are Funds clean and clear? :

5) Brief Description of Corporate Activities:

6) Banking Details

Banking Details for Receiving Founds in US Dollars (USD) by Wire Transfer via SWIFT MT103
BENEFICIARY BANK NAME : Nombre del banco Beneficiario final y receptor de los USD
Beneficiary Bank Branch Address, : Dirección COMPLETA de la sucursal del banco donde el beneficiario tiene
City & Country la cuenta, con nombre de ciudad y país
Beneficiary Account Name Holder : El nombre COMPLETO de la cuenta del beneficiario de la transferencia.
(CON EL NOMBRE ESTA REGISTRADA EN EL BANCO LA
CUENTA.)
Beneficiary Address of the : Dirección completa de la compañía beneficiaria tal cual como aparece en el
Account banco del beneficiario con nombre de ciudad y país
SWIFT code/BIC : Coloque el código SWIFT
Fedwire ABA Routing Number : Para cuentas en USA, numero de FEDWIRE que es igual al ABA #
Bank Account Number : Numero de cuenta (TODO JUNTO BIEN COMPLETO Y
CORRECTO…OJO CONFIRMA SEAN LOS CORRECTOS.).
Type of Account : Nombre del tipo de cuenta: CORRIENTE? CORRIENTE VIP?....ETC,
ETC.
Bank Telephone : Numero telefónico del banco con códigos de marcado bien completes:
EJEMPLO: + (1) 000-000-0000
Bank Fax : Numero FAX del banco con códigos de marcado bien completos:
EJEMPLO: + (1) 000-000-0000
Bank officer Name : Nombre completo del oficial bancario asignado a la Cta.
Bank Officer Telephone : Numero telefónico del oficial bancario asignado a la cta.
Bank Officer E-mail : Correo electrónico bancario del oficial asignado a la cuenta. ( NO SU
CORREO PERSONAL). ASI: [email protected]
WIRE TRANSFER AMOUNT : Monto en USD de la transferencia en letras y números
DETAIL OF THE WIRE PAYMENT OF ______ obligatorio COLOCAR AQUI EL CONCEPTO
TRANSFER PAYMENT POR EL CUAL PUEDE RECIBIR LA TRANSFERENCIA….FAVOR

DATE:diciembre 12, 2019

(ON CORPORATION’S LETTERHEAD TYPED IN 14 SIZE FONTWITH FULL
ADDRESS, PHONE (+_____) WITH EACH PAGE NUMBERED AND INITIALED.)

COLOCARLO EN INGLES y español

Business Activity of the Account OBLIGATORIO Escriba aquí, una breve descripción de TODA la
actividad económica de la compañía receptora de los USD, tal cual como
esta registrada ante el banco beneficiario de los USD.

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.

Agreed and Accepted by the

Date: diciembre 12, 2019

AQUI FIRMA
_________________________________ AQUI SELLA
Signature
Name:
Title:
Passport Nº:
Country of Issue:
Date of Issue:
Date of Expiry:

DATE:diciembre 12, 2019

(ON CORPORATION’S LETTERHEAD TYPED IN 14 SIZE FONTWITH FULL
ADDRESS, PHONE (+_____) WITH EACH PAGE NUMBERED AND INITIALED.)

PASSPORT COPY

DATE:diciembre 12, 2019