Outlier Client Information Form

1. Please provide the following information:

What is the legal name and operating name of the company?*

What is the company's address?*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Who should the proposal be addressed to?*

First NameLast Name

Title

Email

Phone

Who should invoices be addressed to?

Same as above

First NameLast Name

Email

All persons and entities who own or control, directly or indirectly, 25% or more of the company. Please provide their full names.*

Additional information may be required (i.e. home address and date of birth) where there are queries that we need to clear.

Who will serve as the Compliance Officer for the company?*

First NameLast Name

2. Does the company have any subsidiaries or affiliated entities?*

YesNo

If yes, please provide details, including the jurisdictions in which they operate. *

3. Does the company (including any subsidiaries or affiliated entities) have assets/interests or conduct operations in any country subject to UN, Canadian, US or EU sanctions, or currently enforced ministerial directives?*

YesNo

If yes, please provide further details.*

4. Is the company currently licensed or registered as an MSB in the jurisdiction(s) where it operates?*

YesNoNot applicable

If yes, please provide related details.*

Please provide a copy of the license/registration.

5. Has the company registered with the Bank of Canada under the incoming RPS regime?*

YesNoNot applicable

Click here for information about the RPS regime.

6. Please specify any other registrations the company holds (e.g., OSC, SEC, etc.). Include relevant information related to these registrations.*

Please provide a copy of any other registration(s) the company holds.

7. Has the company undergone a compliance effectiveness review within the past two years?*

YesNo

If yes, please provide the date of the last review and the name of the entity or individual who conducted it.

8. Has the company previously used another service provider for AML compliance advisory? If yes, please explain the reason for the change.

9. Has the company been reviewed or examined by any regulators in the past two years?*

YesNo

If yes, please provide the date of the last review or examination, and indicate whether any fines were assessed.*

Name of the regulator:

10. Is the company currently subject to any pending civil or other litigation?*

YesNo

If yes, please provide details, including the jurisdiction in which the case is filed.*

11. Is there a different person Outlier should contact if we have additional questions?*

YesContact the proposal addressee

Please provide their information here:*

First NameLast Name

Email

Phone

For any questions about this form, please reach out to your Outlier team contact.

The information you provide is encrypted and securely transmitted. It is used solely for onboarding purposes and stored in compliance with our data retention policy.