Customer Due Diligence Form for Potential ... - Amazon S3



1497330-1215390Investors00InvestorsCustomer Due Diligence Form for Potential Afreximbank InvestorsCustomer ProfileName of CompanyCustomer Legal Name(to attach Certificate of Incorporation)Name at Inception(to attach Certificate of Change of Name)Country of IncorporationDate of Incorporation and Registration No.Physical Address:(to include address, telephone numbers and e-mail address)Registered Office Address/Head Office(to include address, telephone numbers and e-mail address)Principal Operating Address(to include address, telephone numbers and e-mail address)Other Existing Investments including Partnerships and ConsortiumsDetails of Subsidiaries or Affiliate Companies within the GroupDetails of Trustee or Nominee Companies (if applicable)Name of the Stock Exchange where Company’s Stock is Traded (if applicable)Name of the Risk Rating Agency and the Current Rating (if applicable):Contact DetailsName of Contact PersonDesignationTelephone NumbersEmail AddressWebsiteSwift: (if applicable)Full Disclosure of Source of Initial Capital(to attach 1) notarized declaration of initial source of capital and 2) notarized statement of net-worth)Reason(s) for investment in AfreximbankProducts and Services OfferedEconomic Sector(e.g. Financing, Industrial, Manufacture, Petroleum, Textile, Oil & Gas, etc.)Details of Product(s) and/or Service (s) OfferedCountries where Products and Services are Offered:(List Countries and not Continents)Contractor(s)/Supplier(s) of ProductsCompany’s NameLocationPhysical AddressContact PersonTelephone No.sFax NoMobileEmailService Type(equipment, furniture, manufactured product, Technology, Services, etc.)RegulationName of Regulatory Body in your jurisdictionOperating LawDate Law was Enacted and came intoDate of Changes and/or Amendments to Existing Laws:ShareholdingShareholding Structure (information about all owners to attach profiles/CV; certified copies of their identification i.e. Relevant passport pages as well as their notarized statements of net-worth including signed declaration of initial sources of capital by key promoters).ManagementMembers of the Board of Directors(To attach profiles/CVs and certified copies of identification. To specify according to executive and non-executive)Executive Management Team and Key Management Staff(To include their titles and positions as well as attach biographies of the individuals are required)Authorized Signatories(To attach certified identification documents and contact details of Person(s) authorized to execute contracts with Afreximbank)Other DetailsName and Contact Details of Legal Advisors:(Physical address/telephone/Mble/Fax/email.etc.)Name and Contact Details of External Auditors:(Physical address/Telephone/Mble/Fax/email, etc.)References: (Banking or Commercial)Details of Shareholders/Directors/Key Executives who hold positions in the public sector/government (both local and foreign) and their respective positions Confirmation of compliance with workplace Safety, Environmental Risk and Social Management Regulations (To attach evidence e.g. appropriate Certification/ Environmental Impact Assessment Report issued by recognized authority) Sanctions: Is the company, company’s shareholders/ Members of the board of directors under any restrictions?(If yes, please provide details)Questionnaire (tick appropriate box) Yes No N/AIs your Company involved money laundering?Is your Company involved in Financing of Terrorism or other financial crimes?Is your Company a shell company? Does your Company have a process in place to identify all counterparties i.e. customers, contractors, employees, and other parties?Does your Company conduct background checks on counterparties to ensure it does not does not deal with parties involved in money laundering, financing of terrorism and other financial crimes?Is your Company compliant with Anti-bribery and Corruption laws and regulations of the operating country(ies)? Has any legal action been brought against the Company before the regulatory organ regarding violations of anti-money laundering and/or terrorist financing laws and regulations? (If Yes, please provide details of name of case and court references and summary of the outcome of court proceedings) Space for any additional information I confirm that the information provided above is true and represents (name of Company)Completed byPosition/TitleDateSignature and StampChecklist of Required Information FORMCHECKBOX Memorandum & Articles of Association (certified copy)/constitution/objects/statutes FORMCHECKBOX Certificate of Incorporation (certified copy) FORMCHECKBOX Certificate of Change of Name (if applicable) FORMCHECKBOX Confirmation of Changes in ownership structure/shareholders in the past 5 years. FORMCHECKBOX Company’s Annual Report and Financial Statements for the past 3 years;? FORMCHECKBOX Board of Directors Resolutions/Mandate FORMCHECKBOX Board of Directors individual profile (CVs) FORMCHECKBOX Information on company’s profile including registered jurisdictions, physical addresses (P.O.Box is not acceptable), Directors including Independent Directors, company’s external?auditors, type of business, etc. FORMCHECKBOX Ownership structure (including key promoter(s), comprehensive list of shareholders, respective percentages of their stakes in company, biographies (CVs) of individual promoters/owners of company with relevant certified passport pages or national identity card. FORMCHECKBOX Declaration of initial sources of funding by key promoters and their notarized statements of net-worth which includes other business interests (shareholding) in other companies and other assets FORMCHECKBOX Name of Parent/Holding Company (if applicable); statutory information to include; Certificate of Incorporation; Memorandum & Articles of Association, Board Members and Shareholding structure FORMCHECKBOX Detailed individual and/or parent company profile and shareholding structure; Board of Directors; key management team; subsidiaries; nominees; trustees; etc. FORMCHECKBOX Biographies (CVs) of key management team of company; FORMCHECKBOX Type of Business, contractor(s) and supplier(s) detailed information; FORMCHECKBOX Supplier(s) information: Provide detailed information about the supplier(s), type of services being offered, telephone/Mobile Nos: #, physical address (es), location(s), etc., if applicable. ................
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