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CIS Form Customer Information Sheet PDF

CBH CIS Form Customer Information

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Creditex Brokerage
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258 views5 pages

CIS Form Customer Information Sheet PDF

CBH CIS Form Customer Information

Uploaded by

Creditex Brokerage
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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Finance Solutions for Business, Real Estate & Entertainment

CLIENT INFORMATION SHEET


IMPORTANT: COMPLETE FORM & DELIVER INFORMATION
ELECTRONICALLY TO: info@creditexbrokers.com

Disclaimer
This document is intended solely for the benefit of firms and individuals seeking to be connected with various funding and
monetization sources. The material enclosed is for informational purposes only and does not constitute an offer or
solicitation to purchase any investment solutions or a recommendation to buy or sell securities nor is it to be construed as
investment advice. Any examples are for illustrative purposes only and do not constitute financial recommendations or
advice. You acknowledge that BlueBanc Capital is NOT a Broker, Finance Company, Financial Advisor or Licensed in any
way, we are solely a Deals Facilitation Service that works with clients to assist them to implement a range of appropriate
Solutions directly with professional service providers. Our role is to connect people, assist in the removal of deal barriers
and peer the right service provider with the right client so customers can achieve a likely successful conclusion.

Copyright Creditex Brokerage Holdco Limited 2011 www.creditexbrokers.com


CLIENT’S LETTERHEAD

CLIENT INFORMATION SHEET


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.

IMPORTANT:
Please select which one of the following:

I want to:
[ ] Enrol in CBHL’s Complete Managed BG Program

(We Issue a BG & Fund it for you)

[ ] Solely Monetize an Existing A Rated Bank BG you already have.


(Note: If you select this option your passport and this CIS has to be notarized.)

[ ] Place an Asset of Cash in a Trade Program


(Note: If you select this option your passport and this CIS has to be notarized.)

Corporate

Full Name of Institution :


Registration Number :
Date of Registration :
Domicile /Jurisdiction :
Postal Address :
Registration Address :
Physical Address :
(if different from Registration Address)
Business Telephone Number :
Business Facsimile Number :
E-mail Address :
Website :
Corporate Officers and Titles :

Initials: _______
CLIENT’S LETTERHEAD

Details of Signatory to Contract – Corporate & Individual

First Name :
Last Name :
Date and Place of Birth :
Nationality :
Passport Number :
Date of Issue of the Passport :
Expiry Date of the Passport :
Title in the Corporation :
Mobile Phone Number :
Home Address :
Home Telephone Number :
Home Facsimile Number :
E-mail Address :

Legal Advisor Name :


Legal Advisor Address :
Legal Advisor Telephone Number :
Legal Advisor Facsimile Number :
Do you speak English? :
If no, what language? :
If English is not listed, please provide the name and co-ordinates of a person you
designate to translate from English to your preferred language.
Translator Name :
Translator Address :
Translator Telephone Number :
Translator Facsimile Number :
Translator E-mail Address :

Details of the Bank Account – Where Funds are held

Bank Name :
Bank Address :
Bank Swift Code :
Account Name :
Account Number :
Account Signatory Name and Title :
Bank Officer Name and Title :
Bank Officer Telephone Number :
Bank Officer Facsimile Number :
Bank Officer E-mail Address :

Initials: _______
CLIENT’S LETTERHEAD

DECLARATION OF NON SOLICITATION


That I, (INSERT YOUR NAME) warrant and attest, with full personal and corporate
responsibility that as the beneficial owner; I have full legal title and authority with no
governing restrictions over the herein described collateral, cash and/or assets and also
acknowledged as such by my depository financial institution.
We hereby grant THE TRANSACTING PRINCIPALS full permission and authority to
verify, confirm, and reconfirm said collateral and/or assets on a bank-to-bank basis and
conduct standard background checks of the collateral and/or assets, and the corporate
entity owning such.
I warrant and attest that I have not authorized any other party to place collateral and/or
assets.
I certify and attest that at no time has your organization or any agent and / or appointee
on your behalf made any offer or solicitation.
I, (INSERT YOUR NAME), hereby declare with full personal and corporate responsibility
under penalty of perjury that the information given above is accurate and true.
By: (INSERT YOUR NAME)

Signed____________________________________________ Date_____/_____/_____

Initials: _______
CLIENT’S LETTERHEAD

ESSENTIAL:
ADDITIONAL SUPPORTING DOCUMENTS
REQUIRED

1.Full Color Copy of Passport

Initials: _______

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