NOMBRE DE LA COMPAA

J-XXXXX
DIRECCIN
+58XXXXXXX Fax: +58XXXXXX
E-Mail: XXXXXX

CLIENT INFORMATION SHEET (C.I.S.) (10 MM USD)

In accordance with Articles 2 through 5 of the Due Diligence Convention and the Federal Banking Commission
Circular of December 1998, and under the US Patriot Act of 2002, as amended in February 2003 concerning the
prevention of money laundering and 305 of the Swiss Criminal Code, the following information may be supplied to
banks and/or other financial institutions for purposes of verification of identity and activities of the Client described
below, and the nature and origin of the funds which are to be utilized. The foregoing is subject to agreement by all
parties to whom this information is provided that they are obligated to respect the privacy rights of the Client and all
individuals described herein, as well as the generally accepted professional standards relating to the maintenance of
confidential information, and to take all appropriate precautions to protect the confidentiality of the information
contained herein, This legal obligation shall remain in full force indefinitely without restriction.
1)

Buyer Full Name

Business Address
Business Registration No.

J-

Telephone

02xxxx

Facsimile

02xxxx

E-Mail Address
2)

Buyer Signatory Full Name

Nationality

VENEZUELAN

Passport No.
Date of Issue
Date of Expiration
Date of Birth
Place of Birth
SSN/Identity No.

V-xxxx

Address
Mobile Telephone
E-Mail Address

DATE: April 11, 2016

NOMBRE DE LA COMPAA
J-XXXXX
DIRECCIN
+58XXXXXXX Fax: +58XXXXXX
E-Mail: XXXXXX

3)

Funds Information
Funds available for 1st tranche

YES

Origin of Funds
Are Funds clean and clear?

YES

4) Brief Description of Corporate Activities:

5)

Banking Details
LOCAL BANK
Bank Name
Address
Clients Name
Account number
Telephone / Fax
Bank Officers Name
FOREING BANK
Bank Name
Address
Clients Name
Account number
ABA
SWIFT
Telephone / Fax
Bank Officers Name
Bank Officers Number

Declaration: We hereby swear under penalty of perjury, that the information provided is both true and accurate. We
are the signatories on the aforementioned bank account. All monies engaged in this transaction are derived from

DATE: April 11, 2016

NOMBRE DE LA COMPAA
J-XXXXX
DIRECCIN
+58XXXXXXX Fax: +58XXXXXX
E-Mail: XXXXXX

non-criminal origin; and, are good, clean and cleared. The origin of funds is in compliance with Anti-MoneyLaundering Policies as set forth by the Financial Action task Force (FATF) 6/01.
INTERMEDIARY BANK
Bank Name
Address
Account number
SWIFT

Agreed and Accepted by the

Date: April 11, 2016

_________________________________
Signature
Name:
Passport #:
Country of Issue: VENEZUELA
Date of Issue: 14/07/2015
Date of Expiry: 21/07/2015

DATE: April 11, 2016

NOMBRE DE LA COMPAA
J-XXXXX
DIRECCIN
+58XXXXXXX Fax: +58XXXXXX
E-Mail: XXXXXX

PASSPORT COPY

DATE: April 11, 2016