SIMPLE CIS

SIMPLE CIS
Name*

First NameLast Name
Applicant*

Individual= Complete Section ACorporation = Complete Section B
Complete A (Required) and B if Applicable

PLEASE COMPLETE ALL QUESTIONS RELEVANT TO YOUR CATEGORY - INCOMPLETE FORMS WILL NOT BE PROCESSED
A - Individual Applicant
Individual's Name*

First NameLast Name
Nationality*
Passport Number*
Country of Issue*
Date of Issue*
Date of Expiration*
Is copy of Passport Attached*

YesNo
Date of Birth*
Place of Birth*
Identity Number/Social Security Number*
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Mobile Telephone Number*
Email*
example@example.com
Business Activity*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Registration Number (if applicable)
Business Phone Number (if applicable)

Area CodePhone Number
Business Email (if applicable)
example@example.com
B - Corporate Applicant

PLEASE COMPLETE ALL QUESTIONS IN THIS SECTION
Corporation Name
Business Activity
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Corporation Business Registration Number
Country of Incorporation
Registered Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Corporate Phone Number

Area CodePhone Number
Corporate Email
example@example.com
Corporation Representative Name
Position
Nationality
Passport Number
Country of Issue
Date of Expiration
Is Copy of Passport Attached?

YesNo2
Date of Birth
Place of Birth
Identity Number/Social Security Number
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Mobile Phone Number

Area CodePhone Number
Email
example@example.com
Is CURRENT Proof of Funds Attached?*

YesNo
Are Funds freely transferrable?*

Yes 1No2
Referred by:*

First NameLast Name
DECLARATION
I hereby under penalty of perjury that the information is both true and accurate.

I, the person issuing this Client Information Summary, am the Signatory on the above referenced Bank Account and confirm that all funds are good, clean, and cleared funds of non-criminal origin, and the origin of funds is in compliance with the Anti-Money Laundering Policies as set out by the appropriate authorities.

Signed Below:
Signatory's Name*

First NameLast Name
Signature*
This Date*

MonthDayYear
Date
OR
Please attach your Passport picture and credentials, and the front and back of your Driver's license - BELOW IN FILE UPLOAD
FILE UPLOAD - SEARCH FILES AND ATTACH THEM HERE*

Browse Files

Cancelof
Please verify that you are human*
Should be Empty:

SIMPLE CIS

Complete A (Required) and B if Applicable

A - Individual Applicant

B - Corporate Applicant

DECLARATION