CLIENT INFORMATION FORM: INDIVIDUALS

EXPLANATORY NOTES

  • Firstline requires this form to be fully completed in order to begin our client relationship with you. Its primary purpose is to ensure that the identity of our clients and their source of funds are properly verified in accordance with national legislation and international guidelines.
  • Do not leave any section blank. State ‘N/A’ if we prompt you to answer anything that is not applicable to your situation. We may request additional information.
  • Copies of all submitted documents should be accompanied by originals for verification. If an original is not produced, the copy must be notarised or certified by a bank officer, member of the judiciary, Member of Parliament or legal practitioner.
A. ABOUT YOU
1. Full Name : *
2. Title:
3. Status: *
4. Date Of Birth: *
5. All Nationalities / Citizenships: *
6. Place of Birth: *
7. T&T Resident?: YesNo
if answer to A.7 is ‘no’
8. Country of Residence:
9. Physical Address: *
10. Mailing Address:

11. Telephone Numbers
Home:
Mobile: *
Work:
Other:

12. Email Address
Primary:
Secondary:

13. Bank Details (If you are not resident in T&T, we require a bank reference letter.)
Primary Bank Name:
Branch Address:
Bank Reference Letter (Enc.? y/n):
B. ID VERIFICATION (If originals not submitted for verification to Firstline, copies must be notarised or certified)
1. ID Type (2 forms):
Number
Country of Issue
Expiry Date dd/mm/yyyy
National ID
Driver’s Permit *
Passport *
2. Address Verification Required for both physical and mailing addresses. Must be no more than 3 months old.
Utility Bill (not mobile)Bank Statement
max. 10MB upload. Hold Ctrl to select multiple files for upload.
C. OCCUPATION Pay slip or job letter required as verification
1. Classification: *

Private SectorPublic Sector
RetiredSelf-Employed
HomemakerStudent
Other:
2. Occupation: *
3. Employer Name:
4. Employer Address:
5. Employer Telephone:
6. Self-Employment If self-employed, please complete this section:
Occupation:
Business Name:
Business Tel #:
VAT Reg #:
Cert. of Incorporation / Trading Licence: Copy enc.? y/n
YesNo
7. Gross Annual Income: *
8. Other Income Source: Should you engage in any activities which provide significant additional source of income, other than the occupation listed above, please list them here along with the names of any relevant business entities as applicable: Please indicate N/A if not applicable to you.*
D. OUR RELATIONSHIP If you select “wealth management” in D1, please complete D5 to D7.
1. Business Activity: *
2. Frequency of Activity:
Other:
3. Will you be conducting business on behalf of, or for the benefit of any other entity or individual through this account?
4. What will be the sources of funding which will provide for the activities that you contemplate to undertake with us?
5. What is your level of direct experience in years with these different forms of investments?
Equities (local)
Equities (foreign)
Bonds
ETFs
Mutual Funds
Commodities
6. What are your investment objectives?
IncomeGrowth & IncomeGrowth
7. What are your current financial goals? (You can be as specific or as preliminary as you like)
Next 2 years
Next 5 years
And beyond…
E. LEGAL INFORMATION
1. Have there ever been any criminal or civil proceedings brought against you? If yes, please describe: *
2. 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: *
F. POLITICIALLY EXPOSED PERSONS
1. Have you been or are you an individual, or the immediate family of, or a close personal or professional associate of: *
Head of State or GovernmentSenior Government, Judicial or Military OfficialsSenior PoliticianSenior executives of state-owned corporationsImportant political party officialsSenior executives of international non-governmental organisationsNone of the Above
2. If you selected any at F1, please give details here:
G. U.S. INDICIA (FATCA) The Government of T&T has agreed with the U.S. to collect data on persons with U.S. indicia
1. Please check the relevant box/es below which applies/apply to you.
U.S. Indicia
Documentation Required - Doc Enc? y/n
U.S. citizen or permanent residentU.S. birthplaceU.S. residence or mailing addressFund Transfer required to U.S. bank accountPower of Attorney granted to U.S. personNot Applicable
W-9 or W-8BEN :
W-9 or W-8BEN or Non-US passport :
W-9 or W-8BEN or Non-US passport :
W-9 or W-8BEN or Non-US passport :
W-9 or W-8BEN or Non-US passport :
H. REQUIRED DOCUMENTS Please enclose the following documents (originals to be seen or copies certified)
1. Two forms of current photo identification (as selected in B1) max. 10MB upload. Hold Ctrl to select multiple files for upload.
2. Proof of physical and mailing address (utility bill or bank statement 3 months to      current) max. 10MB upload. Hold Ctrl to select multiple files for upload.
3. Pay slip or job letter max. 10MB upload. Hold Ctrl to select multiple files for upload.
4. Bank reference letter (if non-resident in T&T) max. 10MB upload. Hold Ctrl to select multiple files for upload.
5. If you are unable to provide a pay slip or job letter and / or you answered yes to      F1, you must complete a Source of Wealth form and provide supporting      documentation max. 10MB upload. Hold Ctrl to select multiple files for upload.
I. YOUR DECLARATION
I * declare that the information I have provided on this form is true and correct to the best of my knowledge. I authorise 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 Firstline may be legally compelled to share my information with local or foreign regulatory organisations.
Date:
If this form has been completed by an intermediary (power of attorney or other authorised individual), Firstline requires original authorization from you on the appointment of your intermediary.
Intermediary Name:
Date:
ID Detail:
Natl IDDPPP
Number:
Seal/ Stamp of intermediary if applicable

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