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Questionnaire

Is the application for ?Natural personLegal entityInvestment structure

1. Personal information

First Name

Middle Name

Last Name

Date of birth

Nationality

Place of birth

Any other nationalityYesNo

Other nationality

2. Contact information

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone Number

Address mail

Contact address (if different)

3. Tax information

Fiscal address

US person (yes/no)YESNO

Sorry we can't Proceed

TIN Number

4. Family information

Marital status

Are you marriedYESNO

First Name

Middle Name

Last Name

Date of birth

Nationality

Place of birth

Any other nationalityYESNO

Other nationality

Do you have childrenYESNO

Children details

First Name

Middle Name

Last Name

Date of birth

Nationality

Place of birth

Any other nationalityYESNO

Other nationality

Do you have other childrenYESNo

Children details

First Name

Middle Name

Last Name

Date

Nationality

Place Of Birth

Any Other NationalityYesNo

Other Nationality

Do you have other childrenYESNo

Children details

First Name

Middle Name

Last Name

Date

Nationality

Place Of Birth

Any Other NationalityYesNo

Other Nationality

Do you have other childrenYESNo

Children details

First Name

Middle Name

Last Name

Date

Nationality

Place Of Birth

Any Other NationalityYesNo

Other Nationality

Do you have other childrenYESNo

Children details

First Name

Middle Name

Last Name

Date

Nationality

Place Of Birth

Any Other NationalityYesNo

Other Nationality

Do you have other childrenYESNo

Children details

First Name

Middle Name

Last Name

Date

Nationality

Place Of Birth

Any Other NationalityYesNo

Other Nationality

Searches

Are You PEP ?YESNO

are you Link to country/ies under sanction ?YESNO

Which Country ?

Have you judicial Procedure?YESNO

Are you under criminal investigation ?YESNO

PEP questionnaire

How are you PEP ?ActivityRCA

Which activity ?

What link ?

What activity has the link ?

Judicial Procedure

Which type of procedure?CommercialCriminal

What are you ?ComplainantDefendant

when did it happen?PastCurrent

What was the decisionguiltyno guilty

was it old?>10 years<10 years

When was it closed ?

are you under criminal investigationYesNo

Criminal investigation ?

Which type of criminal investigation ?

when did it happen?PastCurrent

What was the decisionguiltyno guilty

was it old?>10 years<10 years

When was it closed ?

Current activity

Do you have a professional activity ?YESNO

Activity details ?

Sector of activity

Occupied position

Start date

Name of the company

Location of the company

Academic background

Last Diploma

Date of the last diploma

Sector of study

School / University

Wealth

Amount of total Wealth

Denomination currencyUSDEURGBPCHFJPY

Type of wealth

Deposit in bank transferable securities

Text

Denomination CurrencyUSDEURGBPCHFJPY

Indicative amount

Indicate name of establishment

Country of the establishment

Industrial assets

Denomination CurrencyUSDEURGBPCHFJPY

Indicative amount

Indicate name of the company

Country of the company

Real estate assets

Denomination currencyUSDEURGBPCHFJPY

Indicative amount

Indicate type of RE asset

Country of the RE

Other

Denomination CurrencyUSDEURGBPCHFJPY

Indicative amount

Describe the type of wealth

Annual income

Denomination CurrencyUSDEURGBPCHFJPY

Indicative amount

Type of revenue

Denomination CurrencyUSDEURGBPCHFJPY

Indicative amount

What are the type of revenue ?Savings from salaryBusiness activityInheritance/DonationFinancial investmentReal estate investmentOtherNo other type of revenue

Savings from salary

Denomination CurrencyUSDEURGBPCHFJPY

Indicative amount

What is the activity

Start Date

End Date

Postion

Activity

Name of the company

Salary amount

Business activity

Denomination CurrencyUSDEURGBPCHFJPY

Indicative amount

Date of establishment

Name of the company

Activity of the company

Background of the company

Turnover

Profit

Number of employees

Position (if applicable)

% of shares

Other shareholders >10%

Name of the shareholder

Nationality

Inheritance/Donation

Denomination CurrencyUSDEURGBPCHFJPY

Indicative amount

Date of inheritance / Donation

Name of the donator

Source of wealth

Financial investment

Denomination CurrencyUSD

Indicative amount

Date of investment

Amount invested

Plus-value

Description

Real estate investment

Denomination CurrencyUSD

Indicative amount

Date of acquisition

Price of acquisition

Date of sale

Price of sale

Type of real estate

Location

Other

denomination currencyUSDOption EURGBPCHFJPY

Indicative amount

Information

Description

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