CUSTOMER INFORMATION – NONPERSONAL ACCOUNTS    Download & Print Printer Friendly Version


Prefered Branch:

I. UPDATE INFORMATION
1 Date: (dd/mm/yyyy) 
2

II. ACCOUNT INFORMATION
1 Client’s Name (including “Trading As”): 
2 Primary Business Address: 
3 Mailing Address (if different): 
4 Telephone and Telefax Number: 
5 Banking relationships at other institutions (past or present) include name and address
 
Name of Bank or financial institution Address/Branch
   
   
If no other relationships, state reason:
Has the customer closed or been requested to close accounts with an FI over the last five years:
If yes, name of FI and reason:  
6 Source of funds and purpose of account – describe what the use the account or product in detail:

III. COMMERCIAL INFORMATION
1. Type of legal entity:   
   
 Other
2. Place and date of incorporation/formation:
 3. Describe Evidence of Legal Status Reviewed and year of issuance (e.g. Articles of Incorporation, Certificate of Good Standing, Partnership Agreement, etc.)
4. Is client publicly-traded or state-owned?

If yes, name of exchange or government:

Stock Exchange Symbol: 		5. Is parent publicly-traded or state-owned

If yes, name of exchange or government:

Stock Exchange Symbol:
6. Taxpayer Identification Number:
 
7. Note any recent (<18 months): Mergers, acquisitions, major changes in ownership which occurred (or are in process):
8. Note any significant expected or recent (<18 months) changes in product mix or business activities (i.e. opened new selling locations in recent year, etc.):
9. Is the Company (or related business) experiencing: Financial difficulties, Industry/Business investigation, Government intervention,business/management reputation concerns, etc.?

If yes, explain:
10. Affiliates and subsidiaries:
Subsidiaries:
Name Industry Segment Type of Business % Owned
Affiliates:
Name Industry Segment Type of Business % Owned
11. List names, addresses and percentage of ownership of principal owners:
Owner’s Name Address % Ownership
Has the entity been under the same ownership for the past 10 years?
         
12. List names, titles, country of legal residence of principal corporate officers/senior management:
Board Members:
Name Title Address
Senior Management:
Name Title Address
 
13. Lines of business and description of business Operations, including size of business activity/market share and number of employees:
14. Type of Business:
15. No. of years in business:
16. Primary locations and trade areas:
17. Names and location of major suppliers:
18. Names and location of major customers:

IV. FINANCIAL INFORMATION
1. Summarize Financial Highlights Year Year Year
Total assets
Total liabilities
Total annual sales/revenue
Net profits
Date of Financial Statement:(dd/mm/yyyy)    
Audited:   Name of External Auditor:
3. Summarize general description of assets:
4. Summarize general description of liabilities:
5. External credit report obtained?  
6. Client’s annual report obtained?  

V. ANTICIPATED ACTIVITY – MANDATORY INFORMATION FOR AML ASSESSMENT
1. Anticipated account activity information: [Here is an example of how the answer to this question should read]:
  Range & Average Monthly Volume (#)
10 – 20 Average = 12		 Range & Average Transaction Size ($)
$100 - $200 Average = $125		  
 
Activity Range & Average Monthly Volume Range & Average Transaction Size ($)  
Funds Transfer Debits  
Funds Transfer Credits  
Cash Deposits  
Cash Withdrawals  
Cheque Disbursements  
Cheque Deposits  
Other expected activity Profile Limit
2. Are there seasonal variations in volume?
 
Explain  
3. Describe anticipated client revenue from products and services

VI. REFERENCES
Banking and Commercial References
Type of Reference Name, Address and
Telephone Number		 Method of Collaboration
WORK NO. (COUNTRY CODE/AREA CODE/NO.) HOME NO. (COUNTRY CODE/AREA CODE/NO.) FAX NO. (COUNTRY CODE/AREA CODE/NO.)
     
MOBILE NO. (COUNTRY CODE/AREA CODE/NO.) WORK E-MAIL: HOME E-MAIL
     
PAGER NO. (COUNTRY CODE/AREA CODE/NO.) WEBSITE URL WIRELESS E-MAIL
 

VII. FGB’S INTERNAL ASSESSMENT - ANTI-MONEY LAUNDERING
AML Risk Assessment:
       
Comments
Is the client’s anticipated activity commensurate with the client’s annual sales/income based on the industry?
 
Explain
Are there any Politically Exposed Persons (public figures) involved in the ownership or management of this entity?
   
 
If yes, list public figures 
CUSTOMER INFORMATION
(FOR FIRST GLOBAL USE ONLY)
ACCOUNT OFFICER NUMBER
 RELATIONSHIP OFFICER
 BRANCH
 DATE
FOR ON LINE ACCESS
CUSTOMER NUMBER:
 USER ID

CUSTOMER AUTHORIZATION
We undertake to immediately advise you in writing of any change in any form of identification including but not limited to change of names, addresses,management, ownership and structure and agree to provide such documentation as may be relevant.
Signed by:  
Signed by:  
Signed by:  
FGB’S AUTHORIZATION
Signed by:  
Signed by:  
(President or Designee, if necessary)

 I ACCEPT*

I/We certify that the information I/we provided on this application is correct and complete. You may, from time to time, give any credit and other information about me/us, including any information on this Form to and receive such information from, any: (a) Credit Bureau or Reporting Agency; (b) Person with whom I may have or propose to have financial dealings; (c) First Global Bank Limited and its subsidiaries or affiliates; and (d) Person in connection with any dealings I have or propose to have with you.

We undertake to immediately advise you in writing of any change in any form of identification including but not limited to change of names and addresses and agree to provide such documentation as may be relevant.

I/we agree that you may use that information to establish and maintain any relationship with you and to offer me any services from time to time as permitted by law.