Form for Contracting Services*

Please complete all required sections to initiate formal legal engagement and due diligence processes in accordance with applicable laws.

1. Customer Information (To be completed by individuals or company representatives):

FULL NAME *

ELECTRONIC MAIL *

NATIONALITY *

GENDER

OCCUPATION / POSITION

BIRTHDATE

Politically Exposed Person* (PEP)

YesNo

Have you been subjected to any type of investigation/ demand/ complaint/ procedure

YesNo

• Note: Please provide supporting documentation for all information provided. (Copy of Passport (s), Identification (s), Assembly that grants power of signature, as well as any other document that proves your identity and quality).

2. Customer information (To be completed by companies):

NAME AND TYPE OF ENTITY:

PLACE OF INCORPORATION

COMMERCIAL REGISTRY NO

R.N.C OR TAX ID NO

Full name(s) of the final beneficiaries

Example name of beneficiaryExample name 2

• Note: please provide supporting documentation for all the information provided (copy of incorporation documents Tax Id number or R.N.C., Copy of Mercantile Registry. Proof of Ownership by the Final Beneficiaries , copy of the identification document of the final beneficiaries , as well as any other that supports the information contained in this document.

3. Contact information:

ADDRESS (STREET, NO, SECTOR, LOCAL)

CITY/ PROVINCE/ STATE

COUNTRY

TELEPHONE (RESIDENTIAL/ WORK)

MOBILE PHONE

URL WEBSITE

MAIL(S)

4. Source of funds:

DESCRIPTION

5. Description of activities carried out by the client:

DESCRIPTION OF ACTIVITIES

6. Scope(s) of services required:

DESCRIPTION/ JURISDICTION

• Note: This form must be completed and/or updated by all new and existing clients in accordance with Law No. 155-17, Against Money Laundering and Terrorism Financing, promulgated on June 1, 2017 in the Dominican Republic.

By the client

I, the applicant, understand that if I have made any false or misleading statement in the information provided in this document, the application may be voided. However, the work already carried out and the documents (publications and services of all kinds) supplied by and in force at the time the work was carried out or the goods delivered, and all expenses and disbursements made in the name of the applicant shall be reimbursed by the applicant. If the address of the offices is used, I am exempt from any liability consecrating it only as a place of documentary reception and not assumed as a place of operations of the acquired company. I/We warrant and warrant that the information I/We have provided today in support of this application is true and accurate and that I/We have not omitted any material fact, for which I/We release the Company from all legal, civil and criminal liability as well as their representatives or employees for the efforts in information handled and carried out in this application .

Name:

Position:

Digital Signature*

Trace su firma aquí / Draw your signature here