Questionnaire

    For know-your-customer and anti-money laundering purposes we are asking you to provide the following information:

    1. Registered Name of Company? (as it appears on government-issued documentation)

    2. Entity Type (ex. Corporation, Partnership, LLC, Trust, Government Agency, etc.)

    3. Physical Street Address (P.O. Boxes are not acceptable)

    4. Registered Office Address (P.O. Boxes are not acceptable)

    5. Phone Number

    6. Fax Number

    7. Contact Person (full name)

    8. E-Mail Address

    9. Taxpayer Number (or that of Parent Company) or VAT Number

    10. Business Type (Description of the primary type of business activity)

    11. Countries of Operation (list each country the Entity has business operations with.)