Agribank

Customer Due Diligence Form for Legal Persons

Section 1 - Applicant for Business Identification

Company Name

Company Registration number

Country of Registration

Date of Incorporation

Registered Address

Operational Address

different from registered

Telephone number

Entity type

Ownership Structure

Are there any offshore jurisdictions involved in the structure?

Yes

Section 2 - Contact Person

Official Full Name

Designation

Date of Birth

Place of birth

Nationality

Residential Address

ID/Passport number

Telephone number

Section 3 - Business Activity

Industry type

Licensed activity

Yes

Company website

Add more

Section 4 - Transaction Information

Type of accounts required

Source of Funds (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

Connection with other countries:

Country

Connection type*

Add more

Relationship with applicant

Source of Funds (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

What payments methods does the company accept? (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

Payment Service Providers (Type N/A if you are not using any PSPs)

Targeted Jurisdictions (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

What payments methods does the company accept? (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

Payment Service Providers (Type N/A if you are not using any PSPs)

Targeted Jurisdictions (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

What payments methods does the company accept? (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

Payment Service Providers (Type N/A if you are not using any PSPs)

Targeted Jurisdictions (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

Amount of payments in EUR per month

Number of payments per month

Countries from where payments will be received (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

Countries to where payments will be made (To select multiple values, kindly hold down the SHIFT or CMD/CTRL button when selecting)

Section 5 - Beneficial owner information

Add more

Section 6 - Upload Section

Corporate Structure Chart

Section 7 – PEP Declaration

Politically exposed persons (PEPs) are individuals who are or have been entrusted with prominent public functions, for example Heads of State or of Government, senior politicians, senior Government, judicial or military officials, senior executives of state owned corporations, and important political party officials. Family members and close associates of such persons are also considered as PEPs.

Are you and/or any other natural person detailed in this form a politically exposed person?

Yes No