MR. NOBORU IDE
07/01/1972
SUGURU IDE
MOTOKO IDE
JAPANESE
44-6, Mogamicho, Momoyama, Fushimi-ku, Kyoto,Japan.
44-6, Mogamicho, Momoyama, Fushimi-ku, Kyoto,Japan.
Noboru Ide, Managing Director
noboru.ide@mel.muratec.co.jp
noboru.ide@mel.muratec.co.jp
Managing Director
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+81-75-606-1011
+81-75-606-1011
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BUSINESS
N/A
MZ2160040
...................................................................Branch
Foreign Account Tax Compliance Act (“FATCA”)
Account Number
Name
Country of Residence/Registration
Country of Birth/Incorporation
Please check’’ ” ‘Yes’ or ‘No’ for each of the following questions
1. Are you a U.S. Resident?
2. Are you a U.S. Citizen?
3. Do you hold a U.S. Permanent Resident Card (Green Card)?
4. Is your entity a foreign entity where there is substantial “US ownership” ?
i.e.10% or more (for company/non-individuals)
Yes / No
Applicant’s Signature
Applicant’s Name
Date
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Mr. Noboru Ide
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Account Opening Form Supplement (use additional copies, if required)
This form must be completed by any individual/non-individual/entity who wishes to open a Bank Account/have been maintaining one.
I hereby confirm the information provided above is true, accurate & complete.
Subject to applicable local laws, I hereby consent for Prime Bank Limited, Bangladesh or any of its affiliates (including branches)
(Collectively “the Bank”) to share my information with domestic/U.S. regulators or tax authorities where necessary to establish my tax
liabilities in any jurisdiction.
Where required by domestic or U.S. regulators or tax authorities, I consent and agree that the Bank may withhold from my account(s), such
amounts as may be required according to applicable laws, regulations and directives.
I undertake to notify the Bank within 30 (thirty) calendar days if there is a change in any information which I have provided to the Bank.
A/C Opening Officer
(With Name Seal, Signature & Date)
BM/OM
(With Name Seal, Signature & Date)
MR. NOBORU IDE
JAPANESE
JAPAN
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See Chapter 14 | Para 9 APP5IgO
FORI,{ QA1Z
(Fqw tt ttnclertuking to lte.firrnislted bt;.fitreign nationuls resiclent in fSangludesh attd t'otnltttntrs urrd
.firm,s who,se head o//ices u'e. out,side Runglaclesh fbr tntinlatning hanlr uccount )
]b.
'l'hc Ilauirgcr.
(Nanre and ackiress ol llank)
D.'lr Sir'.
ll\Ye hercby, ccrtiiir that thc crcdits paid into mylour a.ccount u,ith.vonr bank rclate nomrally' to myiour
trading busincss in Bangladesh onl,v and consisl of the fbllorving:-
(f{ere ,slute the principul sowr.:e,y ./iotu whic'h '[ult* pttt'metrls itrlo the acc'ount ure derived, e.g. li{tvtu€nt,\
receit'cd.fbr gootls sold, ,\tilling generul nutw'e ol'good';).
In consideration of' the llangladesh llank agreeing to dispense rvith rnyiour conrpletirtg Irorm A-7 rrr
respect of'every credit to lnv,'crul accr)unt, other than fiom nou-resident acconnt, Irrve undertalie that Ill,\i'e
n,ill not rnake ar.ailable to any llerson ol firm in llangladesh any for:eign cult-enc)i u,hich may be at
nry/clur disposal, against reimburseirrent in Taka. r'vithout llrst having obtarnecl the perntission of tlre
Banglatlesh Llank (through nn Authorised Dealer) by completing Forrrr A-7 in rl:spect ol the l'aka
payment to rny/orlr account. Ii\\'e lurthcr agree to contplctc I'orrn,'\-7 in respect of anv paynlents into thc
account rvhich may uot be directl.v conncrcted r.vith my/our trading aciivitics in }3angladesh. or n'lticlt
rcpreserlt rcnrittances receirrecl fi'otu overseas.
Yours t-aithtirlly,
,\ i gr r trt to't o_f ap p I i r: o nt
Datcd
Bangladesh..
\\re cerltty that to tlre best of oul kno'ur,ledge and belief the infbnralion given above is colrect.
Slunqt and Signuture o/'
rluthorised Deqler
Note: Thrs tbrm shoulci be courpleted in orr original and subrnitted to the Authorised Dealer r'vitlt wltom
the account is clesirecl to he opened fol being preselrred in th'^ respective accourlt openirrg tile.
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