CLIENT INFORMATION FORM: FOR INSTITUTIONS

Please complete this form in full and submit along with any required attachments. State ‘N/A’ if we prompt you to answer anything that is not applicable to your situation. Do not leave any section blank. We may request additional information.
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:
12. Information on all shareholders with at minimum 10% ownership in company : (if privately held please also complete our Institutional Supplement form).
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:
13. Company Description: lines of business, types of customers & the geographical regions served
1. Products & services / 2. Customer types : *
Geographical regions:*
14. Purpose of the Account: *
Type of business activity: asset management, trading, financing, specific investment, other
Proposed frequency of activity: monthly, quarterly, other:
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
17. Information on all officers authorised to transact business for the company’s account. Please also complete our Institutional Supplement Form per individual
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'

1. Incorporation Documents (Certificate & Articles of Incorporation, Bye-Laws or equivalents)
Please upload supporting documents:
max. 10MB upload. Hold Ctrl to select multiple files for upload.

2. Most recent annual or corporate return

Please upload supporting documents:
max. 10MB upload. Hold Ctrl to select multiple files for upload.

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

Please upload supporting documents:
max. 10MB upload. Hold Ctrl to select multiple files for upload.

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.)

Please upload supporting documents:
max. 10MB upload. Hold Ctrl to select multiple files for upload.

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

Please upload supporting documents:
max. 10MB upload. Hold Ctrl to select multiple files for upload.

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

Please upload supporting documents:
max. 10MB upload. Hold Ctrl to select multiple files for upload.

7. Signed Client Agreement (as applicable)

Please upload supporting documents:
max. 10MB upload. Hold Ctrl to select multiple files for upload.

8. Partnership Agreement (as applicable)

Please upload supporting documents:
max. 10MB upload. Hold Ctrl to select multiple files for upload.

9. Deed of Trust (as applicable)

Please upload supporting documents:
max. 10MB upload. Hold Ctrl to select multiple files for upload.
23. DECLARATION OF DIRECTOR OR COMPANY SECRETARY

I * certify that the nature of the company’s business is as described at # 13 and that I am authorised to enter the company into this business relationship. I further declare that all of the information 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 that Firstline may be legally compelled to share company information with local or foreign regulatory organisations.

Name: *
Title:
Date: *

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