AcroForm
CLIENT-INFORMATION-PROFILE.pdf
CONFIDENTIAL Client Information Profile (CIP) (CIP version 01/21) All information provided within this CIP form is confidential. This information is requested by law and in compliance with anti- money laundering legislation. Any information that you volunteer in this form will be held in the strictest confidence and will not be disclosed to any third party outside of our identity verification processes. Failure to provide full, correct and true information may lead to refusal of your application. Information given in this form may also help us to provide you with the correct services and facilities and may assist us in identifying products and services that are tailored to your own specific needs and requirements. This information will NOT be filed by any third party and will remain confidential at all times. SECTION (1): ABOUT YOU FAMILY NAME: FORENAME(S): DATE OF BIRTH: NATIONALITY: MARITAL STATUS: Married Divorced PASSPORT NUMBER: Separated Widowed PASSPORT EXPIRY DATE: Single PLACE OF ISSUE: If Married; FULL NAME OF SPOUSE: OCCUPATION OR PROFESSION: NUMBER OF DEPENDANTS: PROFESSIONAL QUALIFICATIONS: STATE OF HEALTH: Good Fair Poor PERSONAL CONTACT INFORMATION YOUR RESIDENTIAL ADDRESS: Please include international dialling codes. MOBILE NUMBER: Town: HOME TELEPHONE: Postal / Zip Code: OFFICE TELEPHONE: COUNTRY: FAX: HAVE YOU EVER BEEN A RESIDENT OF ANOTHER COUNTRY IN THE PAST 10 YEARS? Yes PREFERRED TELEPHONE NUMBER: No If YES; PLEASE STATE PREVIOUS COUNTRIES OF RESIDENCE: EMAIL ADDRESS: Please provide a confidential email address
Please provide the below information on your main principal company. This means that if your company is a group of companies, please provide information on the main trading parent or group company. If your company is a Special Purpose Vehicle or Private Subsidiary of a public company, please provide full details on the intended trading company that will be applying for the facilities. SECTION (2): ABOUT YOUR PRINCIPAL COMPANY NAME OF CORPORATION: Company Number REGISTERED OFFICE OF CORPORATION: Please provide full postal address of Registered Office JURISDICTION OF INCORPORATION: Limited Company Limited Liability Partnership Partnership Public / Listed Company Tick Box if Special Purpose Vehicle SPV ONLY DATE TRADING STARTED (OR PLANS TO START): This Year: Last Year: This Year: Last Year: CHF Euro (€) GBP (£) USD ($) OTHER Authorised Director Other: Please specify: Beneficial Owner Majority Shareholder or Senior Partner AUTHORISED CAPITAL FULLY PAID CAPITAL Please provide a full correspondence address for receiving confidential documents. This address does not need to be the Registered Office of the Company but MUST be an authorised address of the Company or its trading premises/offices. DATE OF INCORPORATION: TYPE OF INCORPORATION: WHAT IS THE MAIN BUSINESS OR PURPOSE OF THE COMPANY? NUMBER OF EMPLOYEES: TURNOVER OF THE COMPANY: NET PROFIT OF THE COMPANY: CURRENCY: YOUR POSITION WITHIN THE COMPANY: SHARECAPITAL: TRADING ADDRESS ADDRESS FOR ALL CORRESPONDENCE: TOWN POSTAL CODE COUNTRY
Please provide information about the Directors/Officers and Shareholders of your principal company. LIST OF DIRECTORS: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: COMPANY SECRETARY: Full Name: Date of Birth: Shareholding %’age: LIST OF SHAREHOLDERS: If different from the person(s) named above. There is no need to complete if you are a Public Company with more than 12 shareholders. If Shareholder is a corporation or trust, please state the name of the corporation or trust. Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Full Name: Date of Birth: Shareholding %’age: Please continue on a separate sheet if required. Ever been made subject to bankruptcy or insolvency order or have been made bankrupt? Ever entered into a Individual Voluntary Arrangement (IVA) or Company Voluntary Arrangement (CVA)? Ever been banned from acting as a Company Director? Been convicted of a criminal offence for anything other than motoring offences? Yes No Yes No Yes No Yes No Have any of the above stated Directors; If ‘YES’ to any of the above, please provide details:
Please complete this page is as much details as possible. Failure to complete this page may delay your application. SECTION (3): ASSET & LIABILITY STATEMENT Assets State Currency Liabilities State Currency CHF Euro (€) GBP (£) USD ($) CHF Euro (€) GBP (£) USD ($) PERSONAL (FIRST DIRECTOR OR BENEFICIAL OWNER) Value of Private Primary Residence: Residential Loans and Mortgages: Real Estate Property: Commercial Loans and Mortgages: Liquid or Cash Accounts: Bank Loans / Overdrafts: Investments: (Quoted Stocks & Bonds) Other Credit or Loans: Other: (please state) Other: (please state) Value of Company Shareholding: Cars / Boats / Aircraft: Hire Purchase of Lease Contracts: TOTAL PERSONAL ASSETS: TOTAL PERSONAL LIABILITIES: CORPORATE / COMPANY ASSETS & LIABILITIES Real Estate Property: Secured Loans and Mortgages: Liquid or Cash Accounts: Loans Or Overdrafts: Investments: Other Liabilities: Cars / Boats / Aircraft: Hire Purchase & Lease Contracts: Debtors: Creditors: TOTAL CORPORATE ASSETS: TOTAL CORPORATE LIABILITIES: The above information will remain confidential at all times
Please provide us with details of your bankers and legal representative who will be conveying the intended transaction. SECTION (4): ABOUT YOUR COMPANY BANKERS NAME OF BANK: Please provide full details of your company bankers ADDRESS OF YOUR BANK / BRANCH: TOWN POSTAL CODE COUNTRY PRINCIPAL ACCOUNT NAME: ACCOUNT NUMBER: BIC or SWIFT CODE: NAME OF ACCOUNT MANAGER: How Long has the Company banked here: years SECTION (5): ABOUT YOUR ATTORNEY / SOLICITOR or LEGAL REPRESENTATIVE NAME OF LAW FIRM: Please provide full details of your company lawyers NAME OF ATTORNEY or SOLICITOR: ADDRESS : TOWN: POSTAL CODE: COUNTRY: TELEPHONE: FAX: EMAIL ADDRESS:
SECTION (6): BROKER OF RECORD (if applicable) If you have been introduced to us by a broker, please give their name below. NAME OF YOUR BROKER: SECTION (7): ABOUT YOUR REQUIREMENTS STANDBY L/C PREFERRED Please complete the following questions about the services you require. Collateral Transfer (‘leasing’ of Bank Guarantee or SBLC) BANK GUARANTEE Credit Line against existing Bank Instrument or Bond Corporate Loan (Secured) Private Equity or Stakeholder Investment Other: Please specify VALUE OR AMOUNT OF FACILITY REQUIRED: CURRENCY: Swiss Franc (CHF) Euro (€) GBP British Sterling (£) We regret that we no longer issue in US Dollar ($) TERM OF FACILITY REQUIRED: In months (from 12 to 72 months) SECTION (8): IDENTITY PROOFS REQUIRED IMPORTANT: Please provide the following documents when returning this CIP document. Copy Of Passport (Clear Colour Copy) Utility Bill for Proof of Residential Address Copy of Professional Qualifications Copy of Certificate of Incorporation SECTION (9): DECLARATION I understand that the information provided herein and other information that may be attached to this documentation will be examined in accordance with the due diligence procedures defined under Swiss Law. Please accept this form and any attachments as authorisation for IntaCapital Swiss SA to undertake any necessary due diligence investigations, including the search of financial, credit history or criminal databases in respect of myself, my company and any other associated parties. I hereby swear, under penalty of perjury, that the information provided herein and in any other attached documentation is both true and accurate and I further confirm that any funds to be engaged in this transaction contemplated are derived from non-criminal origin; and, are good, clean and cleared. The origin of all funds are in compliance with Anti-Money Laundering Policies set forth by the Financial Action Task Force (FATF) 6/01. Signed: Signed: Dated: