Appendix I CUSTOMER IDENTIFICATION FORM by wku51683

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									                                       Anti-Money Laundering Compliance Programme




Appendix I

CUSTOMER IDENTIFICATION FORM

 Customer Information          Business Information


 Customer Name:                Type of business:

 Company Name:                                     Wholesale               Retail

                               Description of business/Primary Area of Trade:

 Company Representative:

            Name:

            Position:

 Company Representative:

            Name:

            Position:
                               Shipping Address


                               Address:



 Business Address              City:

                               State:
 Address:
                               Country:

                               Telephone:
 City:
                               Facsimile:
 State:

 Country:

 Telephone:

 Facsimile:
                                                                                Anti-Money Laundering Compliance Programme




Individual Identification                                                Company/Business Identification

Individual Customer/Corporate representative should                      Company/Business should provide the following
provide the following identification:                                    identification:

Photo ID (including description and signature):                                             Proof of Incorporation

                      License:                                                              Partnership Agreement

                      Passport:                                                             Association Document

                      Other:                                                                Business License

                                                                                            Valid Proof of Registration
Secondary ID
                                                                                            Other:
                      Credit Card:

                      Other:




                                                            Transaction Detail

Projected Typical Purchase:
                                                      (in US dollars)




Business References:
                                                                         Bank References:
  1.
                   (name)                  (phone number)                  4.
                                                                                         (name)               (phone number)
  2.
                   (name)                  (phone number)                  5.
                                                                                         (name)               (phone number)
  3.
                   (name)                  (phone number)                  6.
                                                                                         (name)               (phone number)




Signed by                                                                 Approved By:


Customer:                                                                 Manager

Salesperson:




                      57133.000009 MIAMI 196617v1

								
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