Due Diligence Questionnaire

Form Type *

Company

Person

Name of registering person *

E-mail address of registering person *

Company name, name or designation: *

Legal form: *

Registration number (if available)

Address of the registered seat or head-office: *

Names of the members of the representatives body or legal representatives: *

If a member of the representative body or a legal representative is a legal person, please provide its company name, name or designation, registration number (if available) and address of the registered seat or head-office:

Please confirm whether, with respect to this engagement, the company you represent is acting for [its/his/her] own account or on behalf of a beneficial owner (the latter term includes trust arrangements, foundations and acting on the instruction of another).

Please check one of the following and provide the required information: *

You confirm that the company you represent is acting for its own account with respect to this engagement.

The company you represent acts on behalf of a beneficial owner. You provide the following information as to the beneficial owner.

Name of the beneficial owner: *

Please check one of the following three alternatives and provide the required information: *

The company you represent is listed on a stock exchange (Note: inclusion is over-the –counter trading or similar markets is not sufficient).

The company you represent is a direct or indirect wholly owned subsidiary of a company listed on a stock exchange (Note: inclusion is over-the –counter trading or similar markets is not sufficient).

Neither the company you represent nor its parent company are listed on a stock exchange. Accordingly, you provide the following information:

Stock exchange: *

Name of parent company and stock exchange: *

You confirm that no individual has direct or indirect control over more than 25% of the capital or the voting rights of the company you represent; or

You will enclose in the upload area below an organizational chart showing individual holdings in the company you represent exceeding 25% of the capital or the voting rights. (Note: in case of multi-layer corporate structure, the organizational chart must permit the identification of all individuals directly or indirectly controlling 25% or more of the shares in the company, whether through a majority of voting rights or under a contractual agreement). The names and addresses of these individuals must be included.

Organizational chart *

Files must be less than 8 MB.
Allowed file types: pdf.

Please send us an extract from the commercial register, registry of mutual associations or comparable official register relating to the company you represent. *

Files must be less than 8 MB.
Allowed file types: pdf.

Full name as per identity document *

Identity document (.PDF file) *

Files must be less than 8 MB.
Allowed file types: pdf.

Social Security / Personal Identification number *

Registered home address, city, province, postcode, country *

Contact telephone number(s) *

E-mail address *

Date of birth *

Month

Day

Year

Nationality and place of birth *

Other citizenship(s)

Country of residence

Occupation

Nature of business intended for proposal, geographies involved and expected type of counter-parties (as applicable)

Are you politically involved? *

Yes

Do you have politically involved relatives? If yes, please specify *

Do you have any business relation to any company(ies) owned by a politically involved person? If yes, please specify *

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