Identity Verification Form
Full Name
*
First Name
Last Name
Passport number:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
*
example@example.com
Passport copy Upload
*
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Address proof Upload
*
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File Upload
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1. Please specify names of company’s Beneficial Shareholders (individuals with 25% and /or more of shares, voting rights or control):
*
2. What is your company’s main activity? List top 3 activities:
*
3. What is the source of funds for your company?
*
Salary /Personal savings
Sales /Trading activity
Borrowed from a financial institution or regulated organization
Crowdfunding or reputable unregulated organization
4. Please specify your company projected turnover for the next 12 months:
*
5. Is your company involved in any criminal, tax, money-laundering, fraud, or other similar activities?
*
Yes
No
6. Have you received any convictions or charges against you in any country?
*
Yes
No
7. Have you ever been declared bankrupt or disqualified from being a director in any country?
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Yes
No
8. Have you ever been under sanctions?
*
Yes
No
9. Will your company be engaged in the military, arms trade, casino, strip, gambling, precious metals trade, real estate activity or arranging payments and financial transactions on behalf of clients at any time in the future?
*
Yes
No
10. Are you a politically exposed person (i.e., you are affiliated in commercial, personal, amicable, family or other kind of relationship with another PEP - "Politically Exposed Person" means an individual who is or has at any time in the preceding 12 months been, entrusted with a prominent public function, including either of the following individuals, but not including any middle ranking or more junior official)?
*
Yes
No
DECLARATION:
*
I assure that all the information provided above is true and accurate.
Signature
*
Submit
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