Director And/Or Shareholder Questionnaire

Please complete all fields accurately.

Name of Corporate Applicant *

A. Customer's Particulars

1. Full Name (including any alias): *

Prefix

First Name

Last Name

2. Marital Status *

3. Date of Birth: *

Date

4. Nationality *

5a. Identification Type: *

Identity Card

Passport

5b. Identification Document No.: *

5c. Expiry date of identification document (if applicable): *

Date

6. Home Address *

Unit, Floor, Building, Street

Postal Code, Country

7. Contact Number *

Code

Phone Number

8. Email *

example@example.com

B. Information of income level/source of wealth/source of fund

9. Individual's wealth/Total assets (Expressed in USD) *

10. Description of your source of wealth *

Note: The source of wealth generally refers to how the individual has acquired the declared wealth (i.e. the origins). Therefore, the source of wealth information provided should be sufficiently detailed on how that wealth is acquired, indicating each source (e.g. employment, investment, inheritance, business, borrowings), and details of estimated amounts generated from each of these sources of wealth, to enable one to explain or justify the individual's declared estimated wealth.

11. Description of your source of funds *

Note: Source of funds refers to the origin of the particular funds or other assets which are the subject of the establishment of business relations (e.g. from individual's personal bank account, related company bank account).

12. Estimated annual income (Expressed in USD) *

C. Documents Required

Please upload a copy of identification document (e.g. Identity Card, Passport, etc.) *

Click to upload

or drag and drop files here

Please upload the letter of authority if the individual is acting on behalf of another person

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or drag and drop files here

Please upload a selfie

Click to upload

or drag and drop files here

Please upload a recent address proof (can be a utility bill or bank statement issued in the last 3 months)

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or drag and drop files here

D. Declaration

I hereby declare that the information provided in this form is accurate and complete.

I confirm that any information is found incorrect and/or incomplete that leads a violation of regulations may initiate legal actions, and I accept that I am the responsible party for any and all charges, penalties and violations.

I understand and agree that all documents supplied (including this form) will not be returned to me.

I undertake to notify Golden Brix of any future changes to the above information.

I understand that Golden Brix reserves the right to request for additional documentation/information.

Name of the Customer *

Prefix

First Name

Last Name

Signature *

Sign here

Date Signed *

Date

Director And/Or Shareholder Questionnaire

A. Customer's Particulars

B. Information of income level/source of wealth/source of fund

C. Documents Required

D. Declaration

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