COMPANY IDENTIFICATION FORM

Transcription

1 Please check the attached explanatory notice before completing this form. Section 1: Business Details Client ID - - Legal form Trading Name if applicable Trading Address if applicable - Street Tel Fax address Industry/Business activity NACE code Please tick below the legal form applicable to your company. Tick if applicable and complete. The Company is: European Regulated financial Institution Name of regulator Country European Public Authority Government Department Country If you ticked one of the above 3 categories, the duty to identify the Ultimate Beneficial Owner (Section 2) does not apply. Please go to Section 3 If none of the above categories do apply, please tick below the legal form applicable to your company. Sole proprietorship Partnership (CVA/SCA, GCV/SCS, VOF/SNC) Cooperation (CVOA/SCRI) Public or Private Limited Company (NV/SA, BVBA/SPRL) Trust, Fiduciary, Foundation or De facto Association Non Profit Organisation (VZW/ASBL) OTHER, please specify Please go to Section 2 and complete the requested information below. Section 2: Ownership/ Beneficiary Details - Complete the sub-sections relevant to your business 2A. If the Company is a Sole Proprietorship Complete the following information on the owner. Date of birth D D M M Y Y Y Y Place of birth Country of birth! Please provide a copy of identification for the owner listed above: A copy of valid Belgian ID (both sides) for Belgian Residents. For all others, a copy of valid passport or a copy of valid national EU Identity Card (both sides). Please go to Section 3 1 / 6

2 2B. If the Company is a Public or Private Limited Company, Partnership, Trust, Fiduciary, Foundation, De Facto Association, Cooperation, Non Profit Organisation, or another legal form. Please provide the details of all Ultimate Beneficial Owners of the Company: these are Shareholders, beneficiaries of the company and/or decision makers as defined in our appendix. If there are NO shareholders or beneficiaries ( 25%) who meet the criteria as described in the appendix, please TICK HERE and complete the name(s) of the decision makers below. Then continue to Section 2C if applicable. If not, go to Section 3. Complete the following information on the Ultimate Beneficial Owners - please add an extra sheet if there is not enough space. Ultimate Beneficial Owner 1 Shareholder/Owner 25% Yes No Decision-Maker Yes No If you are a Shareholder/Owner 25%, indicate Ultimate Beneficial Owner 2 Shareholder/Owner 25% Yes No Decision-Maker Yes No If you are a Shareholder/Owner 25%, indicate Ultimate Beneficial Owner 3 Shareholder/Owner 25% Yes No Decision-Maker Yes No If you are a Shareholder/Owner 25%, indicate Ultimate Beneficial Owner 4 Shareholder/Owner 25% Yes No Decision-Maker Yes No If you are a Shareholder/Owner 25%, indicate 2 / 6

3 Ultimate Beneficial Owner 5 Decision-Maker Yes No Ultimate Beneficial Owner 6 Decision-Maker Yes No Ultimate Beneficial Owner 7 Decision-Maker Yes No Ultimate Beneficial Owner 8 Decision-Maker Yes No! Please provide: a copy of identification for each of the Ultimate Beneficial Owners listed above: copy of valid Belgian ID (both sides) for Belgian Residents and for all others, a copy of valid passport or a copy of valid national EU Identity Card (both sides) an organisation chart of the group showing the ownership of the group if the business is owned by another legal entity. Please go to Section 2C if applicable, if not go to Section 3 3 / 6

4 2C. If the Company is owned by another Company which is either listed on a Stock Exchange, or a European Regulated Financial Institution or a European Public Authority (at least 25%), please provide details of the owning company. Complete the following information on the owning company. Owning Company 1 Owning Company 2 Owning Company 3 4 / 6

5 Owning Company 4 Please provide an organisation chart of the group showing the ownership of the group, as the business is owned by another legal entity. Please go to Section 3 Section 3: Authorised Signer(s) Details - ALL BUSINESS TYPES Please provide the details of the persons who have the necessary power of authority to act as a representative of the Company or entity according to its Articles of Association (or equivalent) in your business relationship with Alpha Card. If they are also shown on section 2, only put the name(s) on this section. Complete the following information on the Authorised Signer(s). Authorised Signer 1 Position in Company Authorised Signer 2! Position in Company Please provide a copy of identification for the Authorised Signers listed above: A copy of valid Belgian ID (both sides) for Belgian Residents. For all others, a copy of valid passport or a copy of valid national EU Identity Card (both sides). For all, a proof of address (=copy of the latest utility bill such as gas, water, electricity...). Please go to Section 4 5 / 6

6 Section 4: Declaration by the Authorised Signer(s) listed in Section 3 The informationi have given on this form, including all documents attached, is true and correct. On behalf of the Company and in my capacity as Authorised Signer I confirm that I have the authority of the other persons named in this application to disclose their details to Alpha Card and eventully to the legally authorized entities. Where the information I have provided constitutes personal information, I understand that such information will be processed in compliance with appropriate data protection legislation. Such personal information shall only be obtained for the purposes stated. I undertake to immediately notify Alpha Card, in writing, of any change to the list of Ultimate Beneficial Owners (both shareholders and decision-makers) and to provide a copy of the identity document of the new Ultimate Beneficial Owners. First name Surname First name Surname Signed for and on behalf of the company Signed for and on behalf of the company Date D D M M Y Y Y Y Date D D M M Y Y Y Y Place Place 6 / 6