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 *

Country Code

Phone Number

8. Email *

example@example.com

B. Information of Beneficial Owner

9. Is the above person acting for himself/herself? (If NO, then fill in Onboarding (Individual) for each person/persons whom the above person is acting on behalf of) *

Yes

No

10. Is the above person the owner of cash/ crypto/ equity? (If NO, then fill in Onboarding (Individual) for the owner of cash/crypto/equity) *

Yes

No

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

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

12. 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).

13. 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.

14. Estimated annual income (Expressed in USD) *

D. Account Fund-in Method

15. Description of background/purpose of transaction/service required for Golden Brix *

16. Account Fund-In Method *

Cash

Crypto

Bank Transfer (please provide deposit bank details)

Other

Bank Account No.

Account Holder Name

Bank Name

E. Documents Required

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

Click to upload

or drag and drop files here

PNG, JPG, PDF up to 10MB

Passport_Scan_2024.pdf

2.4MB

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

Click to upload

or drag and drop files here

PNG, JPG, PDF up to 10MB

Please upload a selfie

Click to upload

or drag and drop files here

PNG, JPG up to 10MB

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

Click to upload

or drag and drop files here

PNG, JPG, PDF up to 10MB

F. Declaration

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

I confirm that any information found incorrect and/or incomplete that leads to 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

Onboarding (Individual)

A. Customer's Particulars

B. Information of Beneficial Owner

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

D. Account Fund-in Method

E. Documents Required

F. Declaration

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