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CIS Form

CIS_Form

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Alex
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323 views

CIS Form

CIS_Form

Uploaded by

Alex
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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YOUR COMPANY LETTER HEAD

CIS FORM

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?

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: …………………….

SIGNATURE…………………………………...................
Name:

WITNESS………………………………………......................
Name:
Title:
E-mail:
Phone:
PASSPORT COPY

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