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                                            PLEASE COMPLETE IN BLOCK CAPITALS

WS0001

DATE :


SURNAME :                                     FIRST NAME(S ) :

COMPANY / FIRM (IF APPLICAB LE) :

B USINESS ADDRESS :



                                                            POST / ZIP CODE :


RES IDENTIAL ADDRESS :



                                                            POST / ZIP CODE :


NATIONALITY :                                 DATE OF B IRTH :



PLEASE INDICATE WHICH ADDRESS WE SHOULD CORRESPOND WITH
BUSINESS              RESIDENTI AL
RES IDENTIAL TEL EPHONE NUMB ER :

MOB ILE TEL EPHONE NUMB ER :

B USINESS TELEPHONE NUMB ER :                                             EXT :

EMAIL ADDRESS :

FAX NUMB ER RES IDENTIAL :                          B USINESS :

COUNTRY OF INCORPORATION :

READY MADE COMPANY :
                           First Choice :

                         Second Choice :

OWN CHOICE OF NAME :
                           First Choice :

                         Second Choice :
                                                                                       2 of 5




BENEFI CIAL OWNER(S ) (THIS SECTI ON MUST BE COMPLETED)
SURNAME :                                      FIRST NAME(S ) :

ANY FORMER NAMES :

RES IDENTIAL ADDRESS :



                                                             POST / ZIP CODE :

PASSPORT / IDENTITY CARD NUMB ER :
(delete as appropriate)
NATIONALITY :                                B USINESS OCCUPATION :

TEL EPHONE :                   FAX :                       EMAIL :


SURNAME :                                      FIRST NAME(S ) :

ANY FORMER NAMES :

RES IDENTIAL ADDRESS :



                                                             POST / ZIP CODE :

PASSPORT / IDENTITY CARD NUMB ER :
(delete as appropriate)
NATIONALITY :                                B USINESS OCCUPATION :

TEL EPHONE :                   FAX :                       EMAIL :



SURNAME :                                      FIRST NAME(S ) :

ANY FORMER NAMES :

RES IDENTIAL ADDRESS :



                                                             POST / ZIP CODE :

PASSPORT / IDENTITY CARD NUMB ER :
(delete as appropriate)
NATIONALITY :                                B USINESS OCCUPATION :

TEL EPHONE :                   FAX :                       EMAIL :

               IF THERE ARE MORE B ENEFICIAL OWNERS, PLEAS E CONTINUE ON A S EPARATE S HEET
                                                                                   3 of 5
               DIRECTOR(S) –(DO NOT COM PLETE IF WE ARE PROVIDING NOMINEES)
SURNAME :                                     FIRST NAME(S ) :

ANY FORMER NAMES :

RES IDENTIAL ADDRESS :



                                                            POST / ZIP CODE :

PASSPORT / IDENTITY CARD NUMB ER :
(delete as appropriate)
NATIONALITY :                              B USINESS OCCUPATION :

TEL EPHONE :                 FAX :                        EMAIL :


SURNAME :                                     FIRST NAME(S ) :

ANY FORMER NAMES :

RES IDENTIAL ADDRESS :



                                                            POST / ZIP CODE :

PASSPORT / IDENTITY CARD NUMB ER :
(delete as appropriate)
NATIONALITY :                              B USINESS OCCUPATION :

TEL EPHONE :                 FAX :                        EMAIL :

SECRETARY –(DO NOT COMPLETE IF WE ARE PROVIDING NO MINEES)
SURNAME :                                     FIRST NAME(S ) :

ANY FORMER NAMES :

RES IDENTIAL ADDRESS :



                                                            POST / ZIP CODE :

PASSPORT / IDENTITY CARD NUMB ER :
(delete as appropriate)
NATIONALITY :                              B USINESS OCCUPATION :

TEL EPHONE :                 FAX :                        EMAIL :

REGISTERED OFFICE / RESIDENT AGENT –(DO NOT COMPLETE IF WE ARE PROVIDING DOMICILATION)
NAME OF AGENT :

ADDRESS :



                                                            POST / ZIP CODE :
                                                                                                   4 of 5




FEES FOR S ERVICES REQUIR ED
SERVICES                                                                            STG £   US $

COST OF COMPANY

DOMICILATION

NOMINEE OFFICERS DIRECTOR(S) / S ECRETARY

NOMINEE S HAREHOLDER(S)

POWER OF ATTORNEY (STANDARD) IN
FAVOUR OF
POWER OF ATTORNEY (STANDARD) IN
FAVOUR OF
POWER OF ATTORNEY (NOTORIZED) IN
FAVOUR OF
POWER OF ATTORNEY (NOTORIZED) IN
FAVOUR OF
POWER OF ATTORNEY (NOTORIZED &
LEGALIS ED) IN FAVOUR OF
POWER OF ATTORNEY (NOTORIZED &
LEGALIS ED) IN FAVOUR OF
ASSISTANCE IN OPENING A BANK ACCOUNT IN UK

ASSISTANCE IN OPENING A BANK ACCOUNT OUTS IDE OF UK

MAIL FORWARDING S ERVICE

MAIL FORWARDING / TELEPHONE / FAX S ERVICE

MAIL FORWARDING / TELEPHONE / FAX S ERVICE / EMAIL S ERVICE

NOTORIZATION ADDITIONAL DOCUMENTS

NOTORIZATION / LEGALIZATION ADDITIONAL DOCUMENTS

COURIER OF DOCUMENTS

OTHER S ERVICES

OTHER S ERVICES

BANK CHARGES          PLEASE ADD £25 or $40 IF PAYING BY BANK TRANSFER OR A
                         Q
                      CHE UE DRAWN ON A BANK OUTSIDE O F THE UK

VAT @ 17.5 % MUST BE ADDED TO ALL ORDERS IF WE ARE BILLING YOU IN THE EEC
                                                                              VAT
                                                                            TOTAL
                                                                                                                                            5 of 5




PAYMENT MET HOD

BANK TRANSFER                            Stg£ CHEQUE / DRAFT                       US$ CHEQUE / DRAFT

CAS H               CREDIT CARD (VISA / MASTERCARD)

CREDIT CARD NUMB ER :                                                                           EXPIRY DATE :
I/WE HEREB Y AUTHORIS E YOU TO DEB IT OUR CARD IN THE S UM OF :                                           Stg£                   US$
SIGNATURE :


ANNUAL S ERVICES i .e. REGIS TERED OFFICE, NOMINEE S ERVICES , GOVERNMENT TAXES ,
DISB URS MENTS ETC. SHOULD WE DEB IT FUTUR E FEES TO YOUR CREDIT CARD ?

YES                 NO
I/WE CONFIRM THAT AS BENEFICIAL OWNER(S) WE ACCEPT YOUR TERMS AND CONDITIONS OF BUSINESS AND AGREE TO I NDEMNIFY YOU IN ACCORDANCE WITH THE SAID
TERMS AND CONDITIONS AND THAT THE ABOVE INFORMATION IS TRUE AND CORRECT AND THAT THE ABOVE COMPANY WILL NOT BE USED FOR ANY I LLEGAL
ACTIVITY,MONEY LAUNDERING,TO RECEIVE THE PROCEEDS OF DRUG TRAFFICKING,TERRORIST ACT IVITIES,TRADING IN ARMS AND WEAPONS OR ENGAGE IN ANY INVESTMENT
BUSINESS ON BEHALF OF THIRD PARTIES OR ANY OTHER BUSINESS WITHOUT THE AUTHORISATION OF ANY APPROPRIATE REGULATORY BODY.


SIGNED:                                                        PRINT NAME:

WITNESS ED B Y :                                               WITNESS S IGNATURE:

WITNESS ADDRESS :

                                                                                   POST / ZIP CODE :


WITNESS OCCUPATION :                                                               DATE :

HOW DID YOU HEAR OF US :


 THIS FORM MAY BE FA XE D IF PAYING BY CREDIT CARD OR BA NK TRANS FER,OR POS TED/ COURIE RED
              IF PAYING BY CHE QUE, CASH SHOULD BE SENT BY REGIS TE RED MAIL.


FOR OFFICE US E ONLY
DATE RECEIVED :                                                         RECEIV ED B Y :

PAYMENT REF :                                                           CREDIT CARD AUTHORIS ED :                          YES / NO

CREDIT CARD AUTHORISATION NUMB ER

PROCESS ED B Y :                                                     FEE NOTE NUMB ER :




                                                THE COMPANY STORE LIMITED
                                             A member of The Company Store Group (International) Limited.
                                        Harrington Chambers . 26 North John Street . Liverpool . L2 9RU . England
                        TEL - 0151 258 1258 Freephone U.K. Orderline 0800 26 26 62 FAX - 0151 236 0653 DX 14114 Liverpool
                International Tel +44 151 258 1258 . International Fax +44 151 236 0653 . E-mail enquiries@companystoreworldwide.com

				
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