The Hongkong and Shanghai Banking Corporation Limited
Uttara
For Bank's use only
Personal Information Form: Wholesale Banking
Account No:
HSBC
1. Name of Account (in English Block Letters)
Name of Individual for whom this form is
applicable (in English Block Letters)
Name of Individual in Bangla:
3. Relationship with Account (put / mark):
Director
Minor Accountholder
6. Father's Name
4. Date of Birth 14th May 1961
7. Mother's Name
8. Husbands's/Wife's Name
9. Nationality
Beneficial Owner
Attorney Holder
Bune NAKAMURA
Kayako NAKAMURA
Japanese
10. Gender (putJ mark): / Male
11. Residence Status (put / mark)
Branch
(Foreign nationals must submit a photocopy of their passport and visa)
13. Electronic-Tax ID (E-TIN) No (If available)
18. Permanent Address
Female
Resident
14. Monthly Income (Only for Beneficial Owner)
17. Present Residential Address
YOKOGAWA BRIDGE CORP. (DHAKA BRANCH)
MR. YUZURUNAKAMURA
Signatory
Account Holder
(If necessary, bank staff must follow the guidelines for foreign exchange transactions)
12. Occupation (details with designation) Business (Director)
15. Detail of Source of Fund (Only for Beneficial Owner)
b) E-mail:
Transgender
/ Non-resident
5. Country of Birth Japan
16. ldentity No: National ID No Passport No Driving License No Birth Certificate No
TT1884010
Key Controller
Guardian
Hyogo Prefecture, Nishinomiya City, Kamizonocho 2-70-313.
19. Contact Details a) Telephone No.: +81-90-1586-2721
HyogoPrefecture, Nishinomiya City, Kamizonocho 2-70-313.
nakamury@yokogawa-bridge.co.jp
Shareholder
Others
Others (Please mention ldentity No below)
Issued by The Hongkong and Shanghai Banking Corporation Limited in Bangladesh (November 2020]
Sole Proprietor
** Note: Please print this page and submit with the Appendix for adding additional Connected Parties, as applicable.
Page 3 of 5
The Hongkong and Shanghai Banking Corporation Limited
Uttara
Personal Information Form: Wholesale Banking
For Bank's use only
Account No:
HSBC
1. Name of Account (in English Block Letters)
2. Name of Individualfor whom this form is
applicable (in English Block Letters)
Name of Individual in Bangla:
3. Relationship with Account (put mark):
Director
Minor Accountholder
6. Father's Name
4. Date of Birth 15th June 1962
7. Mother's Name
8. Husbands's/Wife's Name
9. Nationality
Beneficial Owner
Attorney Holder
Kazuaki KAWAKAMI
Akie KAWAKAMI
Japanese
10. Gender (put /mark): / Male
11. Residence Status (put / mark)
Branch
(Foreign nationals must submit a photocopy of their passport and visa)
13. Electronic-Tax ID (E-TUN) No (If available)
18. Permanent Address
Female
Resident
14. Monthly Income (Only for Beneficial Owner)
17. Present Residential Address
YOKOGAWA BRIDGE CORP. (DHAKA BRANCH)
MR. KATSUMI KAWAKAMI
(If necessary, bank staff must follow the guidelines for foreign exchange transactions)
12. Occupation (details with designation) Business (Director)
Signatory
Account Holder
15. Detail of Source of Fund (Only for Beneficial Owner)
Tokyo,Shinagawa-ku, Oi 2-4001.
b) E-mail:
Transgender
Non-resident
5. Country of Birth Japan
Key Controller
Guardian
16. Identity No: National ID No Passport No Driving License No Birth Certificate No Others (Please mention ldentity No below)
19. Contact Details a) Telephone No.: +81-70-4502-7807
Kanagawa Prefecture, Yokohama City, Kanagawa Ward, Katakura 1-30-38-301.
Shareholder
Others
k.kawakami@yokogawa-bridge.co.jp
Sole Proprietor
Issued by The Hongkong and ShanghaiBanking Corporation Limited in Bangladesh (November 2020)
** Note: Please print this page and submit with the Appendix for adding additional Connected Parties, as applicable.
Page 3 of 5
The Hongkong and Shanghai Banking Corporation Limited
Uttara
For Bank's use only
Personal Information Form: Wholesale Banking
Account No:
1. Name of Account (in English Block Letters)
HSBC
2. Name of Individual for whom this form is
applicable (in English Block Letters)
Name of Individual in Bangla:
3. Relationship with Account (put/ mark):
/ Director
Minor Accountholder
6. Father's Name
4. Date of Birth 17th September 1966
7. Mother's Name
8. Husbands's/VWife's Name
9. Nationality
Beneficial Owner
Attorney Holder
Keiji MITSUDA
Motoko MITSUDA
Japanese
10. Gender (put J mark): / Male
11. Residence Status (put / mark)
(Foreign nationals must submit a photocopy of their passport and visa)
Branch
13. Electronic-Tax ID (E-TIN) No (If available)
18. Permanent Address
Female
Resident
14. Monthly Income (Onlyfor Beneficial Owner)
17. Present Residential Address
YOKOGAWA BRIDGE CORP. (DHAKA BRANCH)
(If necessary, bank staff must follow the guidelines for foreign exchange transactions)
12. Occupation (details with designation) Business (Director)
MR. HIROSHI MITSUDA
Signatory Key Controller
Account Holder Guardian
5. Country of Birth
15. Detail of Source of Fund (Only for Beneficial Owner)
b) E-mail:
Transgender
/ Non-resident
16. ldentity No: National |ID No Passport No Driving License No
TS4068700
Osaka Prefecture, Kaizuka City, Kubota 21-8.
Osaka Prefecture, Kaizuka City, Kubota 21-8. 19. Contact Details a) Telephone No.: +81-80-1436-2624
Japan
h.mitsuda@yokogawa-bridge.co.jp
Birth Certificate No Others (Please mention ldentity No below)
Shareholder
Others
Sole Proprietor
Issued by The Hongkong and Shanghai Banking Corporation Limited in Bangladesh [November 2020]
* Note: Please print this page and submit with the Appendix for adding additional Connected Parties, as applicable.
Page 3 of 5
The Hongkong and Shanghai Banking Corporation Limited
Uttara
For Bank's use only
Personal Information Form:Wholesale Banking
Account No:
HSBC
1. Name of Account (in English Block Letters)
2. Name of Individual for vwhom this form is
applicable (in English Block Letters)
Name of Individual in Bangla:
3. Relationship with Account (put / mark):
Director
Minor Accountholder
6. Father's Name
4. Date of Birth 05th November 1965
7. Mother's Name
8. Husbands's/Wife's Name
9. Nationality
Beneficial Owner
Attorney Holder
Hirota NAKANO
Aiko NAKANO
Japanese
10. Gender (put / mark): / Male
11. Residence Status (put / mark)
Branch
(Foreign nationals must submit a photocopy of their passport and visa)
13. Electronic-Tax ID (E-TIN) No (If available)
18. Permanent Address
YOKOGAWA BRIDGE CORP. (DHAKA BRANCH)
14.Monthly Income (Only for Beneficial Owner)
MR. KEITANAKANO
12. Occupation (details with designation) Business (Director)
17. Present Residential Address
Signatory
Account Holder
(If necessary, bank staff must follow the guidelines for foreign exchange transactions)
Female Transgender
Resident V Non-resident
15. Detail of Source of Fund (Only for Beneficial Owner)
b) E-mail:
5. Country of Birth Japan
16. ldentity No: National ID No Passport No Driving License No Birth Certificate No Others (Please mention ldentity No below)
Key Controller
Guardian
Kanagawa Prefecture, Kawasaki City, Aso Ward Kanehodo 3-1-20.
Aichi Prefecture, Nagoya City, Kamenoi 1-30.
19.Contact Details a) Telephone No.: +81-70-1052-3552
nakano@yokokawa-bridge.co.jp
Shareholder
Others
Sole Proprietor
Issued by The Hongkong and Shanghai Banking Corporation Limited in Bangladesh (November 2020|
** Note: Please print this page and submit with the Appendix for adding additional Connected Parties, as applicable.
Page 3 of 5
The Hongkong and Shanghai Banking Corporation Limited
Uttara
Personal Information Form: Wholesale Banking
For Bank's use only
Account No:
1. Name of Account (in English Block Letters)
HSBC
2. Name of Individual for whom this form is
applicable (in English Block Letters)
Name of Individual in Bangla:
3. Relationship with Account (put / mark):
Director
Minor Accountholder
6. Father's Name
4. Date of Birth 10th December 1959
7. Mother's Name
8. Husbands's/Wife's Name
9. Nationality
BeneficialOwner
Attorney Holder
Buntaro YAMASHITA
Maki YAMASHITA
Japanese
10. Gender (put / mark): Male
11. Residence Status (put / mark)
16. ldentity No:
Branch
(Foreign nationals must submit a photocopy of their passport and visa)
13. Electronic-Tax ID (E-TIN) No (If available)
14. Monthly Income (Only for Beneficial Owner)
National |D No
18. Permanent Address
17. Present Residential Address
YOKOGAWA BRIDGE CORP. (DHAKA BRANCH)
(If necessary, bank staff must follow the guidelines for foreign exchange transactions)
12. Occupation (details with designation) Business (Director)
MR. YUJI YAMASHITA
15. Detailof Source of Fund (Only for Beneficial Owner)
Signatory
Account Holder
Female Transgender
Resident VNon-resident
b) E-mail:
5. Country of Birth Japan
Key Controller
Guardian
Passport No Driving License No Birth Cetificate No
19. Contact Details a) Telephone No.: +81-90-8889-5793
Hyogo Prefecture, Kobe City, Kita Ward, Kanokodai Minamimachi 6-6-5.
Nagasaki Prefecture, Nishisonogi-gun, Nagayo-cho, Takadagou-23.
yamasita@yokokawa-bridge.co.jp
Shareholder
Others
Others (Please mention ldentity No below)
Issued by The Hongkong and Shanghai Banking Corporation Limited in Bangladesh (November 2020)
Sole Proprietor
** Note: Please print this page and submit with the Appendix for adding additional Connected Parties, as applicable.
Page 3 of 5
The Hongkong and Shanghai Banking Corporation Limited
Uttara
Personal lInformation Form: Wholesale Banking
For Bank's use only
Account No:
1. Name of Account (in Engish Block Letters)
HSBC
2. Name of Individual for whom this form is
applicable (in English Block Letters)
Name of Individual in Bangla:
3. Relationship with Account (put / mark):
/ Director
Minor AcCountholder
6. Father's Name
4. Date of Birth 24th July 1962
7. Mother's Namne
8. Husbands's/Wife's Name
9. Nationality
Beneficial Owner
Attorney Holder
Shoushin YOSHIDA
Sachiko YOSHIDA
Japanese
10. Gender (put / mark): / Male
11. Residence Status (put J mark)
16. ldentity No:
TT1595851
Branch
(Foreign nationals must submit a photocopy of their passport and visa)
13. Electronic-Tax ID (E-TIN) No (Ifavailable)
14. Monthly Income (Only for Beneficial Owner)
18. Permanent Address
Female
Resident
National ID No Passport No
17. Present Residential Address
YOKOGAWA BRIDGE CORP.(DHAKA BRANCH)
(0f necessary, bank staff must follow the guidelines for foreign exchange transactions)
12. Occupation (details with designation) Business (Director)
MR. AKIHITO YOSHIDA
15. Detail of Source of Fund (Only for Beneficial Owner)
Signatory
Account Holder
b) E-mail:
Transgender
/ Non-resident
5. Country of Birth Japan
Key Controller
Guardian
Osaka Prefecture, Osaka City, Chuo Ward, Fushimi-cho 3-1-1-408.
19. Contact Details a) Telephone No.: +81-90-5887-0934
Ishikawa Prefecture, Kanazawa City, Takematacho 125.
Driving License No Birth Certificate No Others (Please mention ldentity No below)
Shareholder
Others
ak.yoshida@yokogawa-bridge.co.jp
Sole Proprietor
Issued by The Hongkong and Shanghai Banking Corporation Limited in Bangladesh (November 2020)
t* Note: Please print this page and submit with the Appendix for adding additional Connected Parties, as applicable.
Page 3 of 5