1.2 Schedule 1 – Client Particulars CDD

1. IDENTITY

First Name(s)*

Last Name*

Date of Birth

Place of BIrth

Nationality

Passport Number

Expiry Date

Country of Issue

Marital Status

Single
Married
Divorced
Widow/er

Occupation

2. CONTACT DETAILS

Residential Address (P.O. Box not accepted)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address

Same as Previous
Different Postal Address

Postal Address (P.0. Box not accepted)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other Details

Office Telephone Number

Fax Number

Mobile Number

Email*

3. GENERAL QUESTIONS

3.1. In the past seven (7) years have you been:

Disciplined, suspended or fined by a regulatory body in any jurisdiction?

Yes
No

Investigated for professional negligence or malpractice?

Yes
No

Found guilty of any criminal offence?

Yes
No

Declared insolvent or had any property seized or has your estate been wound up?

Yes
No

Under curatorship or failed to satisfy a debt adjudged due?

Yes
No

If the answer is YES to any of these questions, please provide details and substantiating documents.

3.2. If a Mauritian GBL1 company is to be established, please complete the following additional questions:

Does the Individual conduct or carry out financial services business from any jurisdiction other than Mauritius? If yes, please provide the address from which such financial services business is carried out.

Yes
No

Is the Individual regulated in another jurisdiction or has the Applicant applied for a licence from any regulatory authority in any other jurisdiction? If yes, please provide details

Yes
No

Has the Applicant/Beneficial Owner at any time been convicted of any offence involving fraud, or other dishonesty, or any other offence such as an economic offence or money laundering or been subject to penalties for tax evasion (whether or not in Mauritius) relating to companies carrying out financial services business? If yes please supply details.

Yes
No

If the answer is YES to any of these questions, please provide details and substantiating documents.

4. SOURCE OF WEALTH

How was your wealth created?

Countries of Origin (Business Profits)

Countries of Origin (Income from employment)

Countries of Origin (Sale of business)

Countries of Origin (Inheritance)

Countries of Origin (Royalties)

Countries of Origin (Savings/Investments)

Countries of Origin (Gift)

Countries of Origin (Compensation payout)

Countries of Origin (Sale of property)

Countries of Origin (Lottery/Betting)

Countries of Origin (Other)

Total estimated global wealth:

Less than £500,000
£500,000 -£1,000,000
£1,000,000 - £2,000,000
£2,000,000 - £5,000,000
More than £5,000,000

5. Signature

Client Signature*

Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat

Date*

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