Bizaccess Consult - Natural Person Beneficial Ownership Form

BENEFICIAL OWNERSHIP DECLARATION FORM
Part A - The Company
1. Purpose of Beneficial Ownership Information Submission (Please tick)

Other
2. Company Information

a. Full Legal Name of Company

b. TIN of Company (if any)

Cityc. RGD number (if any)

d. Country of Incorporation
a. Full Legal Name of Company

b. TIN of Company (if any)

Cityc. RGD number (if any)

d. Country of Incorporation
Part - B The Beneficial Owner
The Beneficial Owner Information

i. Full first or given name:

ii. Family or Surname

City

iv. Place of Birth
i. Full first or given name:

ii. Family or Surname

Cityiii. Any previous name (e.g. maiden name):

iv. Place of Birth
DayMonthYear
v. Date of Birth
vi. Nationality

vii. Residential Address (including Street name, City, State, Country and Postal/Zip Code)

Cityviii. Service Address (Including Street name, City, Country and Postal/Zip Code)

ix. Digital Address (Eg: GN-00000-0001)
x. Tax Identification Number (TIN). (if applicable)

xi. Telephone/Mobile Number:

Cityxii. Primary ID Type (Voters/National/Drivers)

xiii. Primary ID Number
xiv. Email Address
xv. ID Issuing Country/State/Province:

xvi. Place of Work and Position Held:

City

xiii. Primary ID Number

Are you a Political Exposed Person?
Politically Exposed Person's Status (PEP) is the individual named above a PEP, as a result of holding a position of importance or being a closed relative or associate of a person holding a position of importance?