Date: [Date]
Completed By (Name/Title): [Name, Title]
Business/Entity Name: [Legal Name]
Trading Name (DBA) (If Any): [DBA]
Website (If Any): [URL]
Primary Contact Email/Phone: [Contact]
1.1 Entity Type: ☐ LLC ☐ Corporation ☐ Partnership ☐ Sole proprietorship ☐ Trust ☐ Nonprofit ☐ Other: [**]
1.2 Country/State of Incorporation/Registration: [**]
1.3 Registration/Company Number: [**]
1.4 Tax ID (Last 4 digits only) (Optional): [____]
1.5 Registered Address: [**]
1.6 Operating Address (If Different): [__]
2. Business Activities
2.1 Nature of Business: [Describe goods/services in plain language].
2.2 Industry/Category: [**]
2.3 Date Business Started: [**]
2.4 Countries Where You Operate/Serve Customers: [List]
2.5 Do you operate in any regulated areas? ☐ No ☐ Yes (describe): [__]
3. Ownership and Control
3.1 Beneficial Owners (Individuals who own/control [__]% or more, or as required):
Owner Name: [] | Ownership %: [] | DOB (optional): [] | Country of residence: []
3.2 Controllers/Directors/Managers (If Applicable):
Name: [] | Title: [] | Country: [__]
3.3 Ownership Structure (Brief): [Simple description or attach chart].
3.4 Any nominee shareholders or trusts involved? ☐ No ☐ Yes (explain): [__]
4. Expected Activity (Risk/Usage)
4.1 Reason for Account/Relationship: [**]
4.2 Expected Monthly Transaction Volume: $[**] (estimate)
4.3 Expected Monthly Number of Transactions: [**]
4.4 Typical Transaction Size: $[**]
4.5 Source of Funds: ☐ revenue ☐ investment ☐ loans ☐ other: [**]
4.6 Primary Payment Methods (If Applicable): ☐ bank transfer ☐ card ☐ cash ☐ crypto (where permitted) ☐ other: [**]
5. Compliance Questions
5.1 Sanctions/PEP: To the best of your knowledge, are any beneficial owners/controllers a sanctioned person/entity or a politically exposed person (PEP)? ☐ No ☐ Yes ☐ Unknown (explain).
5.2 Adverse Events (Optional): Any material legal/regulatory actions against the business in the last [**] years? ☐ No ☐ Yes (describe).
5.3 High-Risk Countries: Do you do business with customers/suppliers in high-risk or sanctioned jurisdictions? ☐ No ☐ Yes (list).
5.4 Anti-Fraud Controls (Optional): Describe basic controls you use (e.g., chargeback monitoring, identity checks): [**].
6. Documents Checklist (Attach as Available)
6.1 ☐ Certificate of incorporation/registration
6.2 ☐ Registry extract / good standing certificate
6.3 ☐ Ownership chart / cap table
6.4 ☐ Proof of address (registered/operating)
6.5 ☐ IDs for beneficial owners/controllers
6.6 ☐ Tax registration proof (optional)
6.7 ☐ Financial statements (optional)
6.8 ☐ Other: [List]
7. Certification
7.1 The undersigned certifies that the information provided is true and complete to the best of their knowledge and that they are authorized to provide it on behalf of the business.
Signatures
Authorized Representative: [Full Name]
Title: [Title]
Date: [Date]
Signature: ___________________________