Beneficial Ownership Questionnaire
Please complete this form to disclose all individuals or entities with significant ownership or control over your organization.
Legal Entity Name
*
Entity Type
*
Please Select
Corporation
Limited Liability Company (LLC)
Partnership
Trust
Other
Full Name of Beneficial Owner
*
First Name
Last Name
Role/Relationship to Entity
*
Please Select
Owner
Director
Trustee
Shareholder
Other
Country of Residence
*
Nationality
*
Type of Ownership or Control
*
Direct
Indirect
Percentage of Ownership or Control
*
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
The Last 4 Digits of Your Government-Issued ID (if applicable)
Please provide any additional details regarding beneficial ownership or control.
Signature
*
Submit
Submit
Should be Empty: