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214 views

Wa0002.

Uploaded by

Ataa Pro
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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CLIENT INFORMATION SHEET (CIS)

CLIENT INFORMATION SHEET (CIS ) :

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 conta ined
herein, This legal obligation shall remain in full force indefinitely without restriction.

I hereby submit the following information for your consideration. I understand that this
information will be relied upon, unconditionally, as statements by me of material fact.

CUSTOMER INFORMATION SHEET (CIS ) :


No. INFORMATION QUIRY DETAIL

1 PROFIL

a). Represented By SYARIF HIDAYAT

b). Nationality INDONESIA

c). Passport Number E3451080

d). Date Of Issue JUNE 8TH 2023

e). Date Of Expiration JUNE 8TH 2033

f). Date Of Birth March, 21 th, 1970.

g). Place Of Birth BANDUNG

h). Identity Card No. (KTP) 3204282103700011

i). Contact Address Kp. BABAKAN LOA NO. 23 RT. 001/012 RANCAEKEK KULON ,
RANCAEKEK
j). Contact Telp No. BANDUNG
0811 811 9703

k). Mobile Telp No. 0811 811 9703

l). Email [email protected]

m). Occupation Businessman

n). Company Name PT. BARATA ADI PERKASA

o). Company Registration 9120203703814


p). Office Address Gedung ASCOM Jl. Matraman Raya No 67, Kel. Palmerah,
Kec. Matraman. Kotamadya Jakarta Timur. Indonesia
q). Office Telp No (021) 29613810

r). Office Fax No. -

s). Email [email protected]

2. Address for Mail Gedung ASCOM Jl. Matraman Raya No 67, Kel. Palmerah,
Kec. Matraman. Kotamadya Jakarta Timur. Indonesia
3. Address for Courier Gedung ASCOM Jl. Matraman Raya No 67, Kel. Palmerah,
Kec.Matraman. Kotamadya Jakarta Timur. Indonesia
4. BANK COORDINATE

a). BANK NAME PT.BANK UOB INDONESIA

b). Branch and Address JL.M. Hasanudin Serang Plaza Blok.II No 3-7 Serang 42112 Banten

c). Account Numbers 3163004176 (IDR)


3169000474 (USD)
d). Account Name PT. BARATA ADI PERKASA

e). Account signatory SYARIF HIDAYAT

f). SWIFT Code BBIJIDJAXXX

g). Bank Officer Name Tina Nafirda

h). Bank Telephone No. +62 254-200153 Ext. 31000

i). Bank Officer Email [email protected]

5. Affirmation
I hereby swear under the full penalty of perjury, that the information provided herein is both
true and accurate. I am in control of the assets stated bellow and have signatory authority on
the aforementioned bank account and have full authority to execute all contracts and
agreements relating to pleading the assets for a loan. The funds are in full compliance with
the anti-money laundering policies set forth by Financial Action Task Force (FATF) 6/01.

Signed, July 05th, 2023

SIGNATORY

Name : Syarif Hidayat


Title : President Director
Passport Number : E3451080
Issue Date : JUNE 8TH 2023
Expire Date : JUNE 8TH 2033
Country of Issuance : Indonesia

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