1. Legal Name:

*

Trading Name: if different to legal name:

2. Registered Address:

*

3. Branch / Mailing Address:

if different to registered address

4. Place & Date of Incorporation:

also, file #*

5. Tax ID:

6. Telephone Numbers:

*

7. Fax Number:

8. Company Website:

Email Address:

9. List all regulated or licensed activities that you conduct:

10. List all supervisory authorities / regulatory organisations that govern your activities:

11. Primary Bank Name: if not based in T&T, we require a bank reference letter

Branch Address:

Name:

Address:

Telephone:

D.O.B. or incorporation:

Country of birth or incorporation:

Government-issued photo identification #1: PP/DP/NI:

Government-issued photo identification #2: PP/DP/NI

Occupation or Business:

1. Products & services / 2. Customer types : *

Geographical regions:*

Type of business activity: asset management, trading, financing, specific investment, other—Please choose an option—Asset ManagementTradingFinancingSpecific InvestmentOther

Proposed frequency of activity: monthly, quarterly, other:—Please choose an option—MonthlyQuarterlyOther

15. Will you be conducting business on behalf of, or for the benefit of any other entity or individual through this account? Provide further detail if so: *

0

16. What would be the source or sources of funding which will provide for the activities that you contemplate to undertake with Firstline? *

0

Name: *

Title: *

Telephone: *

Email: *

Photo ID #1: PP/DP/NI: *

Photo ID #2: PP/DP/NI: *

Name: *

Title: *

Telephone: *

Email: *

Photo ID #1: PP/DP/NI: *

Photo ID #2: PP/DP/NI: *

Name:

Title:

Telephone:

Email:

Photo ID #1: PP/DP/NI:

Photo ID #2: PP/DP/NI:

Name:

Title:

Telephone:

Email:

Photo ID #1: PP/DP/NI:

Photo ID #2: PP/DP/NI:

18. Confirmation of written compliance policies and procedures which minimise the risks of the business being susceptible to money launderers and terrorist financiers: *

Yes, we have such policiesNo, we do not have such policies

19. Detail any criminal or civil proceedings brought against the company, a key employee or any affiliate in the past 3 years: *
0

20. Are your Authorised Officers, 10% shareholders, directors, senior officers or spouses 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:
0

21. Are your Authorised Officers, 10% shareholders, directors, senior officers, their spouses or immediate family, Politically Exposed Persons? Do they 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, is anyone related or closely connected to any such individual? YesNo
If yes, please give details: 0

22. Please attach the following documents and tick if complete:if not based in T&T, all copies must be notarised & 'original'

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1. Incorporation Documents (Certificate & Articles of Incorporation, Bye-Laws or equivalents)

2. Most recent annual or corporate return

3. Last 3 years of audited financial statements or Management accounts

4. Two forms of current photo identification and Institutional Supplement Form per person listed in question #s 12 & 17 as well as for all Directors & the Company Secretary (NB: all IDs must be certified original seen and no older than 3 months from the time of submitting this form.)

5. Incorp. documents & most recent annual or corporate return for 10%+ shareholder if an incorporated entity

6. Bank reference letter (if not based in T&T)

7. Signed Client Agreement (as applicable)

8. Partnership Agreement (as applicable)

9. Deed of Trust (as applicable)

Name: *

Title:

Date: *