(Please print in your company letter head) CLIENT INFORMATION SHEET Date: Reference Code: LHSM/2MCD/122014 In accordance with Articles 2 through 5 of the Due Diligence Convention and the Federal Banking Commission Circular of December 1998, concerning the prevention of money laundering and Article 305 of the Swiss Criminal Code, the following information must be supplied to banks and / or financial institutions for purposes of verification of identity and activities of the investing Member, and nature and origin of Assets, which are to be utilized. All parties are obligated to respect professional secrecy and take all appropriate precautions to protect the confidentiality of the information it holds in respect of their activities. This legal obligation shall remain in effect at all times. Client Information Client / Signatory Name : Nationality : Passport Number : Date of Issue : Expiration Date : Issued by : Social Security Number : Date of Birth : Place of Birth : Home Information Street address : City/ State / ZIP : Telephone : Facsimile : CLIENT INFORMATION SHEET, Page 2 Business Information Business Name : Street Address : Registered Office : Registered Number : Telephone : Facsimile : Legal Advisor Name : Legal Advisor Address : Mailing Address Information Street Address : City / State / ZIP : E-mail Address : Bank Information Name of Bank : Branch : Street Address : City / State / ZIP : Telephone : Facsimile : S.W.I.F.T. Code : Bank Officer #1 : Bank Officer #2 : Account Name : Account Number : Account Signatory : CLIENT INFORMATION SHEET, Page 3 Fund available : Origin of Funds: Are these Funds free and Clear? YES or NO Brief description of Corporate Activity: Acknowledgment: I hereby confirm and verify the above named authorized signatory is the owner of the above stated Assets and / or the duly appointed Corporate Officer, and is the sole signatory on the bank account, and has full authority to execute all contracts and agreements relating to any Joint Venture Project Funding Investment Corperation Agreements (JVPFICA), and I fully understand, that all future communications will be directly between Principals or their councel with no intermediary involvement. Furthermore, I confirm these Assets are free and clear with no liens or encumbrances and are of non-criminal origin. I hereby verify, affirm and swear under penalty of perjury, that I AM THE SIGNATORY of the account and that the funds / asset BELONGS TO ME, that is the above statements and information are accurate and true. Signed this ________________, 2014 Signature : Name : Passport Number : Country of Issuance :
Posted on: Sat, 20 Dec 2014 15:18:59 +0000
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