Client Information Profile

All information provided within this CIP form is confidential as per the Privacy Policies presented at Axcona Capital website. This information is requested by law and in compliance with anti-money laundering legislation. Any information that you volunteer in this form will be held in the strictest confidence and will not be disclosed to any third party outside of our identity verification processes. Failure to provide full, correct, and true information may lead to refusal of your application. Information given in this form may also help us to provide you with the correct services and facilities and may assist us in identifying products and services that are tailored to your own specific needs and requirements.

This information will NOT be filed by any third party and will remain confidential at all times.
This application is subject to further individual and corporate KYC, KYB & AML verification procedures.

SECTION 1 – ABOUT YOU

FAMILY NAME: *

FORENAME(S): *

DATE OF BIRTH *//

NATIONALITY: *

YOUR RESIDENTIAL ADDRESS: *

Address Line 1

City

State / Province / Region

Postal Code

Country

PASSPORT NUMBER: *

PASSPORT EXPIRY DATE: *

PLACE OF ISSUE: *

MOBILE NUMBER: *

HOME NUMBER:

OFFICE TELEPHONE:

FAX:

PREFFERRED TELEPHONE NUMBER: *

EMAIL *

MARITAL STATUS: *

FULL NAME OF SPOUSE: *

OCCUPATION OR PROFESSION: *

NUMBER OF DEFENDANTS: *

PROFESSIONAL QUALIFICATIONS: *

STATE OF HEALTH: *

Good
Fair
Poor

HAVE YOU EVER BEEN A RESIDENT OF ANOTHER COUNTRY IN THE PAST 10 YEARS? *

Yes
No

IF “YES”, PLEASE STATE YOUR PREVIOUS COUNTRIES OF RESIDENCE: *

Please provide the below information on your main principal company. This means that, if your company is a group of companies, please provide information on the main trading parent of the group company. If your company is a Special Purpose Vehicle or Private Subsidiary of a public company, please provide full details on the intended trading company that will be applying for the facilities.

SECTION 2 – ABOUT YOUR PRINCIPAL COMPANY

NAME OF CORPORATION: *

Company Number *

REGISTERED OFFICE OF CORPORATION: *

DATE OF INCORPORATION: *

JURISDICTION OF INCORPORATION: *

TYPE OF INCORPORATION: *

Limited Company
Limited Liability Partnership
Partnership
Public / Listed Company

WHAT IS THE MAIN BUSINESS OR PURPOSE OF THE COMPANY? *

Tick Box if Special Purpose Vehicle

SPV ONLY

NUMBER OF EMPLOYEES: *

DATE TRADING STARTED (OR PLANS TO START): *

TURNOVER OF THE COMPANY (US $):

NET PROFIT OF THE COMPANY(US $):

YOUR POSITION WITHIN THE COMPANY *

Beneficial Owner
Authorized Director
Majority Shareholder or Senior Partner
Other

Please Specify: *

Please provide a full correspondence address for receiving confidential documents. This address does not need to be the Registered Office of the Company but must be an authorized address of the Company or its trading premises/offices.

TRADING ADDRESS: *

Address Line 1

City

State / Province / Region

Postal Code

Country

Please provide information about the Directors / Officers and Shareholders of your principal company.

LIST OF DIRECTORS:

Full Name: *

Date of Birth: *

Shareholding %’age: *

Full Name:

Date of Birth:

Shareholding %’age:

Full Name:

Date of Birth:

Shareholding %’age:

Full Name:

Date of Birth:

Shareholding %’age:

Full Name:

Date of Birth:

Shareholding %’age:

Full Name:

Date of Birth:

Shareholding %’age:

LIST OF SHAREHOLDERS:

If different from the person(s) named above. There is no need to complete if you are a Public Company with more than 12 shareholders. If Shareholder is a corporation or trust, please state the name of the corporation or trust.

Full Name: *

Date of Birth: *

Shareholding %’age: *

Full Name:

Date of Birth:

Shareholding %’age:

Full Name:

Date of Birth:

Shareholding %’age:

Full Name:

Date of Birth:

Shareholding %’age:

Full Name:

Date of Birth:

Shareholding %’age:

Full Name:

Date of Birth:

Shareholding %’age:

Ever been made subject to bankruptcy or insolvency order or have been made bankrupt? *

Yes
No

Ever entered into an Individual Voluntary Arrangement (IVA) or Company Voluntary Arrangement (CVA)? *

Yes
No

Ever been banned from acting as a Company Director? *

Yes
No

Been convicted of a criminal offence for anything other than motoring offences? *

Yes
No

Please provide details : *

Please provide us with details of your bankers and legal representative who will be conveying the intended transaction.

SECTION 3 – ABOUT YOUR COMPANY BANKERS

Please provide full details of your company bankers.

NAME OF BANK: *

ADDRESS OF YOUR BANK / BRANCH: *

TOWN: *

POSTAL / ZIP CODE: *

COUNTRY: *

PRINCIPAL ACCOUNT NAME: *

ACCOUNT NUMBER: *

BIC / SWIFT CODE: *

NAME OF ACCOUNT MANAGER: *

HOW LONG HAS THE COMPANY BANKED HERE: *

SECTION 4 – ABOUT YOUR ATTORNEY / SOLLICITOR or LEGAL REPRESENTATIVE

Please provide full details of your company bankers.

NAME OF LAW FIRM:

NAME OF ATTORNEY or SOLLICITOR:

ADDRESS:

TOWN:

POSTAL / ZIP CODE:

COUNTRY:

TELEPHONE:

FAX:

EMAIL ADDRESS:

SECTION 5 – BROKER OF RECORD (if applicable)

If you have been introduced to us by a broker, please give their name below.

NAME OF YOUR BROKER:

SECTION 6 – ABOUT YOUR REQUIREMENTS

Please complete the following questions about the services you require.

VALUE OR AMOUNT OF FACILITY REQUIRED: *

CURRENCY: *

EURO (€)
US DOLLAR ($)
GBP BRITISH STERLING (£)

TERM OF FACILITY REQUIRED: *

SECTION 7 – IDENTITY PROOFS REQUIRED

IMPORTANT: Please provide the following documents when returning this CIP document: *

Copy of Passport (Clear color copy)
Copy of Professional Qualifications (if applicable)
Utility Bill for Proof of Residential Address
Copy of Certificate of Incorporation (if applicable)

File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

SECTION 8 – DECLARATION

I understand that the information provided herein and other information that may be attached to this documentation will be examined in accordance with the due diligence procedures defined under HK Law. Please accept this form and any attachments as authorization for Axcona Capital Finance & Investment Ltd. to undertake any necessary due diligence investigations, including the search of financial, credit history or criminal databases in respect of myself, my company, and any other associated parties.

I understand & agree

I hereby swear, under penalty of perjury, that the information provided herein and in any other attached documentation is both true and accurate and I further confirm that any funds to be engaged in this transaction contemplated are derived from non-criminal origin and are good, clean, and cleared. The origin of all funds is in compliance with Anti-Money Laundering Policies set forth by the Financial Action Task Force.

I understand & agree

Date *

Client Information Profile

SECTION 1 – ABOUT YOU

SECTION 2 – ABOUT YOUR PRINCIPAL COMPANY

LIST OF DIRECTORS:

LIST OF SHAREHOLDERS:

SECTION 3 – ABOUT YOUR COMPANY BANKERS

SECTION 4 – ABOUT YOUR ATTORNEY / SOLLICITOR or LEGAL REPRESENTATIVE

SECTION 5 – BROKER OF RECORD (if applicable)

SECTION 6 – ABOUT YOUR REQUIREMENTS

SECTION 7 – IDENTITY PROOFS REQUIRED

SECTION 8 – DECLARATION

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