CLIENT INFORMATION FORM: FOR COMPANY OFFICIALS

To be completed by each Director, Company Secretary, Authorised Official and 10%+ Shareholder
1. First Name: *
Last Name: *
2. Full Physical Address: P.O. Box not allowed: *
3. Mailing Address: *
4. Date of Birth:
5. Country of Birth: *
6. Country of Citizenship:*

Dual citizen? *YesNo
Description (if 'Yes'):
7. Country of Residence: required for tax identification *

Multiple residences? * YesNo
Description (if 'Yes'):
8. Two Primary ID Numbers: (Passport, Driver’s Permit, National Identification)*
9. Social Security Number: (or national tax equivalent)
10. Telephone Numbers (Work / Home / Cellular): *
11. Fax Numbers:
12. Email Address:
13. Relationship to Business: *
14. Employer Name:
Employer Address:
15. Have there ever been any criminal or civil proceedings brought against you? If yes, please describe: *
16. Are you or your spouse, singularly or as part of a group, in a position of control or similarly connected to any publicly listed company of any jurisdiction? Please state details:*
17. Are you, your spouse or your immediate family, Politically Exposed Persons? Do you work in a Ministry, Embassy, non-governmental international organisation, or any other institution that represents a government or nation, whether abroad or here in T&T? Even if not, are you related or closely connected to any such individual?
YesNo If yes, please give details
*
18. DECLARATION:

I * declare that the information I have provided on this form is true and correct to the best of my knowledge. I authorize Firstline Securities Limited to obtain independent verification of any information provided in respect of this application or as may be required by law, using any legal means available to it, including but not limited to performing background checks, credit checks, and checks against lists of politically exposed persons and terrorist watch lists. I understand that Firstline may be legally compelled to share my information with local or foreign regulatory organisations.

Date: *

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