Information and Signature form

AccouNT OPENING FoRM Name of the Customer Account Number I I I I I I I I I I I I I I I Unique Customer Identification Code I I I I I I I I I I I Branch Name 0PrimeBank 0PrimeBank ................................................................ Branch PLEASE FILL UP THE FORM IN ENGLISH (CAPITAL LETTER) [Please fill up all fields carefully & strike-out the ones which are not applicable] ACCOUNT OPENING FORM Non-Personal Account Date : I��-��-�-��-�� D New Customer D Existing Customer ExiSting NC No. ,.........,.1 l ---r- 1 ---.--- 1 -,--I ,--I -r--,1 1 ---.. 1 ---.--- 1 --,-- 1 --,---I -r--,1 I The Head of Branch Prime Bank Limited .......................................................... Branch Dear Sir/Madam, Confidential & for Bank's use only A/C No. I J I I I I I I I Unique Customer Identification Code I I I I I I I I I I I Group Code I I I I I I I I I I I I/We am/are applying to open an account with your Branch. My/Our organization and account related detailed information are furnished below: 1st Part:Account Related Information 1. Title ofAccount: I :::::=:::::::::::::::::===:====::::::::::====================::::::::======:::::::::======:::::::::========:::::::::::::::::======� �"'lllf: 2. Type ofAccount-PleaseTick(-v) Osavings □ current OSND OFC OERQ Oothers .............................................................. 3. Currency- PleaseTick(v) D Taka D Dollar D Euro D Pound D Others .................................................................................. 4. Mode of Operation- PleaseTick(v) 0 Singly O Joint O0thers ...................................................................................... 5. Initial Deposit: Amount.......................................... In word ............................................................................................. 6. a) Cheque Book: D Yes D No b) E-Statement: D Yes D No c) Internet Banking: D Yes D No d) Mobile No: �I -��-�-��-�-��-�-��I e) E-mail: ............................................................................ 2 nd Part: Organization Related Information 1. Name of the Organization(Block Letter):....................................................................................................................................... �"'ltlf: ............................................................................................................................................................................... 2. Trade License No: ................................................. Date: ......................... Issuing Authority: .................................................. 3. Registration No: .................................. Date: ......................... Registration Authority & Country: ................................................. Registered Address: ............................................................................................................................................................. 4. VAT Registration No/BIN (if any): ........................................................................................................................................ 5. Electronic Tax ID (E-TIN) No:.............................................................................................................................................. 6. Business/OfficeAddress: .................................................................................................................................................. 7. Type of Organization-PleaseTick(v) D Proprietorship D Partnership D Joint Venture D Private Ltd. Co. 0 Public Ltd. Co. □ Trust ONGO/NPO □ club/Society D Educational Institution D Religious Institution D Others .............................................. 8. Type of Business (Details): D Trading D Service D Manufacturing O0thers ................................................. 9. Nature of Business (Details):............................................................................................................................................... 1O.Annual Turnover:............................................................................................................................................................. 11. Mailing Address: ........................................................................................................................................................ NC Opening officer's signature with Name Seal, Signature & Date Approved by Signature with Name Seal Page 1 ofB ◄ 6PrimeBank ................................................................ Branch Third Part: Applicant's Personal Information Confidential & for Bank's use only NCNo.1 I I I I I I I I I I Unique Customer Identification Code I I I I I I I I I I I I I I Self Attested Photo 1. Name of Customer (Block Letter):......................................................................................................................................................... �"'1'1f: ........................................................................................................................................................................................... 2. Date of Birth:................................................................................................................................................................................. 3.Father's Name................................................................................................................................................................................. 4. Mother's Name:.............................................................................................................................................................................. S. Spouse's Name:.............................................................................................................................................................................. 6. Nationality:............................................................................................. 7. Gender: Male D Female □ Other D 8. Resident Status: Please Tick(../) □ Resident D Non-Resident (If needed instructions on Guideline of Foreign Exchange Transactions to be followed) 9. Occupation (Details): ............................................................ Relation with Organization:.................................................................. 10. Electronic Tax ID(E-TIN) No: ............................................................................................................................................................ 11. a) Present Address: RoadNill: ...................................................... P.O: .......................................... Thana: ......................................... . District: ...................................................... Phone/MobileNo: ................................................... E-mail: .................................................. . b) Permanent Address: RoadNill: ...................................................... P.O: .......................................... Thana: ......................................... . District: ...................................................... Phone/MobileNo: ................................................... E-mail: .................................................. . 12. Identification National ID card No/Passport No/Birth Registration Certificate No: .................................................................................... 13. Share Holdings(%): ........................................................................................................................................................................ Declaration & Signature: I, the undersigned, declare that the information provided above is true. I will provide necessary information/ documents on demand of Bank. NC Opening officer's signature withName Seal, Signature & Date Applicant's name, designation, signature and date: Approved by Signature withName Seal Page3of8 ◄ 6PrimeBank ................................................................ Branch Foreign Account Tax Compliance Act ("FATCA") 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 AccounVhave been maintaining one. 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) I/we hereby confirm the information provided above is true, accurate & complete. Yes I □ □ □ □ No □ □ □ □ Subject to applicable local laws, I/we hereby consent for Prime Bank Limited, Bangladesh or any of its affiliates (including branches) (Collectively "the Bank") to share my/our information's with domestic/U.S. regulators or tax authorities where necessary to establish my/our tax liabilities in any jurisdiction. Where required by domestic or U.S. regulators or tax authorities, I/we consent and agree that the Bank may withhold from my/our account(s), such amounts as may be required according to applicable laws, regulations and directives. I/we undertake to notify the Bank within 30 (thirty) calendar days if there is a change in any information which I/we have provided to the Bank. ✓ Applicant(s) name, designation, signature and date: A/C Opening officer's signature with Name Seal, Signature & Date Approved by Signature with Name Seal ► Page4of8 ✓