NPO / NGO 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 partnerdd@mukuru.com
Full Name of Applicant
Details of Authorised Person completing this form on behalf of the Applicant
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 partnerdd@mukuru.com.

1. Applicant Information and Required Documentation

Please provide the following information and supporting documentation
MM slash DD slash YYYY
Trading Address
Head Office Address (if different)
Who are authorised to establish a business relationship/transact on behalf of the Applicant
Due diligence process on donors?
Internal verification/monitoring process of identification of volunteers?
Internal auditing/monitoring process of funds received/donated
- Known individuals: ______% of total donations - Unknown individuals: ______% of total donations - Entities: ______% of total donations - Political/government parties: ______% of total donations
- Local: ______% of total donations - International: ______% of total donations
Method of Receipt of Donations
- Period for which records are kept - Information contained in records - Applicant’s internal record retention requirements
- Country of Incorporation - Registration/Incorporation Number - Registration/Incorporation Date - Declaration of nominated persons who have control of the Trust - Country in which bank account of the Trust is held - Is the bank account of the Trust audited?
Has Applicant been refused or banned from operating within the last 10 years
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. Trustee / Executive Committee Member Information

Full Name
MM slash DD slash YYYY
Home Address
Has any Trustee / Exco Member ever been convicted or investigated for any crime local or internationally?
Add another Trustee / Executive Member
Full Name
MM slash DD slash YYYY
Home Address

3. Authorised Person Information

Full Name
MM slash DD slash YYYY
Home Address
Has the authorised representative ever been convicted or investigated for any crime local or internationally?

4. Person/s holding 15% of more of Voting Rights in Applicant

Name
MM slash DD slash YYYY
Home Address
Has any person holding voting rights ever been convicted or investigated for any crime local or internationally?

5. Information relating to Service Request

To select multiple, please hold in CTRL or Command keys
Address and contact information of operations within the country to which funds will be remitted

6. Contact Information

Full Name

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
MM slash DD slash YYYY
Consent
Max. file size: 128 MB.
Full Name of Director / CEO
MM slash DD slash YYYY
Consent
Max. file size: 128 MB.