Client Profile Sheet

b. Issued By:
c. Date of Issue:
d. Expiration Date:
.
1.2 ID / Social Security Number
1.3 Date of Birth:
1.3.1 Place of Birth:
.
1.4 Residence Information:
a. Street Address:
b. City/State/Zip:
c. Telephone:
d. Fax:
e. eMail
.
2.0 Business Information:
2.1 Business Name:
a. Street Address:
b. City/State/Zip:
c. Telephone:
d. Fax:
e. eMail
2.2 Registered Office:
2.2.1 Registration Number:
a. Telephone:
b. Fax:
.
3.0 Legal Advisor (Law Firm):
3.1 Mailing Address Information:
a. Street Address:
b. City/State/Zip:
.
4.0 Business Address for Courier
a. Street Address:
b. City/State/Zip:
.
5.0 Bank Information:
5.1 Name of Bank:
a. Branch:
b. Street Address:
c. City/State/Zip:
d. Tel/Fax:
e. SWIFT:
f. Bank Officer #1:
g. Bank Officer #2:
h. Account Name:
i. Account Number:
j. Account Signatory:
.
6.0 Client Account Where Instrument To Be Delivered:
6.1 Name of Bank:
a. Branch:
b. Street Address:
c. City/State/Zip:
d. Tel/Fax:
e. ABA Number:
f. SWIFT:
g. Bank Officer #1:
h. Bank Officer #1:
i. Account Name:
j. Account Number:
.
7.0 Funds Available for this Transaction:
7.1 USD:$ (United States Dollars)
7.2 Origin & Source of Funds:

7.3 Are these Funds free and clear?	Yes No
.
8.0 Brief Description of Corporate Activity: