Juristic Customer KYC / Due Diligence Form

Notes: All information & documentation supplied will only be used for the intended purpose of performing due diligence and will therefore be kept confidential. Please submit all queries related to this document; completed form; and supporting documentation to [email protected]

Full Name

First Last

Website

Contact Number

1. Applicant Information and Required Documentation

Please provide the following information and supporting documentation

Registered Name, Registered Address and Country of incorporation

Trading Name (if different from Registered Name)

Trading Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Head Office Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nature of Business / Activities / Source of income of funds to be remitted

Applicant Shareholding Struture

Identification / verification of every shareholding more than 15% of the issued share capital

Identification / verification of Directors

Identification / verification of Auditors (if applicable)

Has Applicant been refused or banned from operating within the last 10 years

YES

(if yes, provide full details of such incident)

Certified ID document means a clear copy of a national identity document or a valid passport issued by country of origin (containing photograph, name, date of birth and nationality) that has been originally sightedor certified.

2. Director Information

Full Name

First Last

Position / Designation

ID / Passport Number

Date of Birth

Country of Residence

Citizenship

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer (if applicable)

Email Address

Mobile Number

Has any director ever been convicted or investigated for any crime local or internationally?

YES

If yes, please provide full details of each incident:

Add another Director

YES

Full Name

First Last

Position / Designation

ID / Passport Number

Date of Birth

Country of Residence

Citizenship

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer (if applicable)

Email Address

Mobile Number

3. Authorised Representative Information

Full Name

First Last

Position / Designation

ID / Passport Number

Date of Birth

Country of Residence

Citizenship

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer (if applicable)

Email Address

Mobile Number

Has the authorised representative ever been convicted or investigated for any crime local or internationally?

YES

If yes, please provide full details of each incident:

4. Shareholding Structure

% Shareholding

Name

First Last

Date of Birth / Date of Registration or Incorporation

Country of Residence / Incorporation

Citizenship / Incorporation Type

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address

Mobile Number

Has any person holding shares ever been convicted or investigated for any crime local or internationally?

YES

If yes, please provide full details of each incident:

5. Information relating to Service Request

Countries to which funds will be remitted

To select multiple, please hold in CTRL or Command keys

Purpose for which funds will be remitted

Address and contact information of operations within the country to which funds will be remitted

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Estimated volume of total funds to be remitted

Amount

Estimated value of total funds to be remitted

Amount

Estimated number of persons / individuals to whom funds will be remitted

Currency in which funds will be disbursed to recipients

Will the same or different person/s be collecting the remitted funds?

Please provide reason for answer

Does Applicant have any ties with any local / international government or any person of interest?

If Yes, please provide reason for answer

6. Contact Information

Full Name

First Last

Position / Designation

Phone

7. Declaration

We, the undersigned, hereby confirm that the information provided within this document and all supporting documentation provided in respect of this document is, to our knowledge and at the time of completion true and correct. We understand that based on the information provided additional information / documentation might be requested by Remitix Limited.

Full Name of Authorised Person Completing on behalf of Applicant

First Last

Role / Position

Date

Full Name of Director / CEO

First Last

Role / Position

Date