Capitallcoin-Business-KYC - SIN LOGOD

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In addition to this form, please be sure
to include the following documents:
- Entity documentation for company – including incorporation
- Board resolution to open an account
- Proof of address
- Corporate Organization Chart
- List of all Directors, Officers, and majority shareholders for the company
- Copy of Passport for each shareholder that holds 25% or more of the company
Party Details
Business Legal Name:
Registration Number:
Date of Incorporation:
Registered address:
Postal Code:
Country:
Business Website Address:
Email for Company:
Name of Bank/Remittance:

BUSINESS APPLICATION KYC 2 / 5
Transaction Information
Est. Monthly Volume (USD):
Est. Number of Transactions:
Est. Transaction Size
Interested currencies :
Principles of the Company
Name
Title
Authorised Representatives
Name
Title

BUSINESS APPLICATION KYC 3 / 5
Principle 1
Name:
DOB
Passport Number
Home Address
City:
State
Post Code
Country
Title
Email
Principle 2
Name:
DOB
Passport Number
Home Address
City:
State
Post Code
Country
Title
Email
Principle 3
Name:
DOB
Passport Number
Home Address
City:
State
Post Code
Country
Title
Email
Principle 4
Name:
DOB
Passport Number
Home Address
City:
State
Post Code
Country
Title
Email

BUSINESS APPLICATION KYC 4 / 5
Authorised Representative 1
Authorised Representative 2
Name:
DOB
Passport Number
Home Address
City:
State
Post Code
Country
Title
Email
Name:
DOB
Passport Number
Home Address
City:
State
Post Code
Country
Title
Email
Authorised Representative 3
Authorised Representative 4
Name:
DOB
Passport Number
Home Address
City:
State
Post Code
Country
Title
Email
Name:
DOB
Passport Number
Home Address
City:
State
Post Code
Country
Title
Email

BUSINESS APPLICATION KYC 5 / 5
Has this Business had any regulatory or criminal enforcement actions from any
government entities resulting from violations of the Anti-Money Laundering Act and
Counter Financing of Terrorism (AMLA/CFT) laws and regulations?
No
Yes (if so, please detail below)
I confirm that all information contained above, to the best of my knowledge, are true,
accurate and up-to-date.
Acknowledged and agreed on
For:
For:
Signature
Signature
Name and Title:
Name and Title: