Rustel Cisform

CLIENT INFORMATION FORM
Please complete all sections
Name of company (Certificate of Company

Registration Attached)
Section 1 – Know your Customer
Title (Mr / Mrs / Ms / Etc)

What is your full name?
Former names, if any
Any other name(s) used
Date of birth
Place of birth
Nationality
Passport Number
Occupation
Qualifications / Business experience
Residential address:
This must agree with documentation
provided
Correspondence address:
If different from residential address
Home telephone
Work telephone
Fax
Mobile
E-mail address
Website
Preferred method of contact
Portion of beneficial ownership if relevant
(%)
CLIENT INFORMATION FORM, continued
Please complete all sections
Section 2 – Due Diligence – Details on Assets
Please provide detailed information about

what this company will be used for including
full and specific description of the proposed
business activities..
Please list the countries in which business
activities will take place.
Include a list of any significant assets to be

transferred to the company
Declared Value of Assets (in USD.)
Please provide details including names and
addresses of the main trading partners, if
applicable.
It is helpful to an understanding of the

business if any sales literature or brochures,
business plans, financial forecasts or other
information is supplied.
Please include a list of disclosed information.
We must identify how the company is
funded.
Please advise the source / origin of capital
and assets to be transferred to the company.
Please attach any supporting documentation.
(and 3 year history, if available)
Date of commencement of business
Estimated annual turnover
Estimated number of payments into the
company per month
Estimated amount of each payment into the
company per month
Estimated number of payments out of the
company per month
Estimated amount of each payment out of the
company per month
Accounting reference date
Section 3 - Signatures
Signed
Print name
Date
INTERBANK REFERENCE AUTHORITY
Completion of this form will enable a reference to be obtained from your bankers
Section 1 – Personal details
Name
Residential address
Country
Post code
Home telephone number
Section 2 – Banker’s details
Bank name
Bank address
Sort code
SWIFT code
Account number
Please sign and print your name below to the following authority:
Dear Sir or Madam:
Please accept this as your authority to provide a Bank Reference.
We authorise you to deduct charges from my / our account for providing the reference.
Signed
Print name
Date
Money Laundering Abatement and Anti-Terrorist Notification.
Under the International Money Laundering Abatement and Anti-Terrorist

Financing Act of 2001 (the .Act.), the International Securities and Exchange
Commission and the Department of Treasury may require the Company to take certain
action to avoid investments by Prohibited Investors (as defined by the Act). If, following a
subscription or an investment, the Company or any of its authorized representatives
have reason to believe that the undersigned is a Prohibited Investor (or is otherwise in
breach of its obligations, or has made any false representations or provided false identity),
the Company may be obligated to freeze the undersigned’s capital account, either by
restricting all further investments with respect to the undersigned’s interest, as well as any
income, gains and other allocations related to or associated therewith; declining any
redemption or withdrawal requests and/or segregating the assets constituting the
undersigned’s investment with the Company in accordance with applicable regulations. In
such an event, the undersigned shall have no claim against the Company, its managing
member, employees, officers, managers, members, affiliates or agents for any form of
damages that result from any of the aforementioned actions.
(I)(We), the undersigned, represent and covenant that neither (myself)(ourselves), nor
any person controlling, controlled by, or under common control with, (me)(us) with respect to
the contemplated transaction and investment, nor any person having a beneficial
interest therein, is a Prohibited Investor, and that (I)(we) (am)(are) not investing or
engaged in any transaction, and will not invest or engage in any transaction, on behalf of or
for the benefit of any Prohibited Investor. Consent is hereby given to you, and to all parties
concerned, to verify all information and to disclose this transaction to financial institutions
and law enforcement, as required.
Name of Subscriber:__________________________________________________________
Authorized Signature: _______________________________Date:_____________________
Print Name and Title (if applicable):______________________________________________
NOTARY
State of _______________________)
) ss.
County of _____________________)
On this ______ day of _____________, 2018, before me, ____________________________,

(Name of Notary)
Personally appeared _________________________________________________,

□ Personally known to me,
□ Proved to me on the basis of satisfactory evidence, to be the person whose name is
subscribed to the within instrument and acknowledged to me that he executed the
same in his authorized capacity, and that by his signature on the instrument, the
person or entity upon whose behalf the person acted, executed the instrument.
WITNESS my hand and official seal:
_____________________________________
Signature of Notary

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CLIENT INFORMATION FORM

Please complete all sections

Name of company (Certificate of Company

Section 1 – Know your Customer

Title (Mr / Mrs / Ms / Etc)

Please complete all sections

Section 2 – Due Diligence – Details on Assets

Please provide detailed information about

Include a list of any significant assets to be

It is helpful to an understanding of the

Section 1 – Personal details

Home telephone number

Section 2 – Banker’s details

Dear Sir or Madam:

Please accept this as your authority to provide a Bank Reference.

Under the International Money Laundering Abatement and Anti-Terrorist

Authorized Signature: ___________Date:_

Print Name and Title (if applicable):______________________________________________

On this day of _, 2018, before me, ______________________,

Personally appeared _________________________________________________,

WITNESS my hand and official seal:

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