Beruflich Dokumente
Kultur Dokumente
This information is sought under The Commonwealth of Samoa Anti-Money Laundering and Combating
of Financing of Terrorism Act, 2015 (as amended)
................................................
……………………………………………….
Registered Address:…………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………..
Physical / Operational Address: (where the operations of company are carried out)
………………………………………………………………………………………………………………………………………………………….
Company’s Representative
KYC/01/17/Rev:00
Page 1
FORM- 027/SMAA
B. Individuals
KYC/01/17/Rev:00
Page 2
FORM- 027/SMAA
Unrestricted √
Restricted (specify)
Part 6 – Declaration
I, the undersigned, hereby declare that all particulars stated above are correct to the best of my
knowledge and belief, and I make this solemn declaration conscientiously, believing the same to be true.
□Certificate of Shareholders
KYC/01/17/Rev:00
Page 3