Wilderness Holdings Limited Company

Wilderness Holdings Limited

Dividend declaration
Shareholder Type: Company
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of shareholder:
We hereby confirm that my source of funds is from Source Name *

We hereby certify that we are not an un-discharged bankrupt and that there are no legal proceedings against me by any creditors, and our source of funds do not represent any proceeds of criminal conduct or money laundering as defined by the anti-money laundering legislations in Mauritius.

Our original or certified copies of Customer Due Diligence documentation will be made available to the Company, upon request without delays.

We hereby confirm that our contact email address is correct from the email received.
Yes or No
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Any other comment
We hereby consent to the Company to wire the said dividend to the attached wiring details and completely indemnify the Company, should there be any loss of funds from the wiring details provided.
We also acknowledge that the Company can halt the payment if there is a mismatch between our name reflecting on the share register and the beneficiary’s name the funds being remitted.
Signature:
COMPANY
Certificate of incorporation

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Proof of registered office address

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Register of directors

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Register of shareholders

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Proof of banking details

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Should be Empty:

Wilderness Holdings Limited