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 partnerdd@mukuru.com
Full Name

1. Applicant Information and Required Documentation

Please provide the following information and supporting documentation
Trading Address
Head Office Address (if different)
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. Director Information

Full Name
MM slash DD slash YYYY
Home Address
Has any director ever been convicted or investigated for any crime local or internationally?
Add another Director
Full Name
MM slash DD slash YYYY
Home Address

3. Authorised Representative 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. Shareholding Structure

Name
MM slash DD slash YYYY
Home Address
Has any person holding shares 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
Full Name of Director / CEO
MM slash DD slash YYYY
Consent