DATE : XX.XX.

2023

CLIENT INFORMATION SHEET

IN ACCORDANCE WITH ARTICLES TWO (2) THROUGH FIVE (5) OF THE DUE DILIGENCE CONVENTION
AND THE FEDERAL MARKETING COMMISSION CIRCULAR OF DECEMBER 1998, CONCERNING THE
PREVENTION OF MONEY LAUNDERING, THE FOLLOWING INFORMATION MAY BE SUPPLIED TO BANKS
AND/OR OTHER FEDERAL INSTITUTIONS FOR PURPOSES OF VERIFICATION.

FULL CLIENT NAME:

NATIONALITY:
PASSPORT
DATE OF ISSUANCE:
DATE OF EXPIRY:
TELEPHONE
BUSINESS ADDRESS:
NAME OF THE COMPANY:
REGISTER NUMBER
EMAIL
. BANK:
ADDRESS:
ACCOUNT NAME:
ACCOUNT NUMBER:
ABA/IBAN:
SWIFT CODE:
BANK PHONE:
BANK OFFICER / TITLE:
PHONE

Signature
:

Name / Title :

Passport Number :

Date of Issue :

Date of Expiry :

Country of Issuance : BRAZIL

ANNEX 1:

PASSPORT COPY OR NATIONAL ID COPY

COLE AQUI O RG OU PASSAPORTE

ANNEX 2

CERTIFICATE OF INCORPORATION OR REGISTRATION

Declaration: I'm xxxxxxxxxxxxxxxxxxxxx hereby swear under penalty of perjury, that the information
provided is both true and accurate. We are the signatories on the aforementioned bank account.
All monies engaged in this transaction are derived from non-criminal origin; and are good, clean,
and cleared. The origin of funds is in compliance withAnti-Money-Laundering Policies as set
forth by the Financial Action task Force (FATF) 6/01.
For and on behalf of
Company -l

Stamp Signature

END DOCUMENTS