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Cis Form - Modelo

This 4-page document provides client information for paymaster services, including personal details of Admilson Gomes de Oliveira, a Brazilian national. It lists his passport number, date of birth, place of birth, origin of funds, and bank account information. It also includes a signature confirming the accuracy of the information and a copy of his passport and proof of residential address.

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Flavio Sabino
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© © All Rights Reserved
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2K views4 pages

Cis Form - Modelo

This 4-page document provides client information for paymaster services, including personal details of Admilson Gomes de Oliveira, a Brazilian national. It lists his passport number, date of birth, place of birth, origin of funds, and bank account information. It also includes a signature confirming the accuracy of the information and a copy of his passport and proof of residential address.

Uploaded by

Flavio Sabino
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

CLIENT INFORMATION SHEET

FOR PAYMASTER SERVICES


DATE: Nov 05, 2018

In accordance with Articles 2 and 5 of the due diligence and federal banking commission
circular of December 1999, concerning the prevention of money laundering, and Article 305 of
the Swiss Criminal Code, the following information may be supplied to banks and to financial
institutions for purposes of verification of identity and activities of the investing member, and
the nature and origin of the funds which are to be utilized.

Client Full Name ADMILSON GOMES DE OLIVEIRA


Nationality BRASILEIRO
Passport Number FU534227
Issued By BRA
Issue Date 16 DE NOVEMBRO 2017
Expiration Date 15 DE NOVEMBRO 2027
Social Security Number (MEDICARE NO:) if N/A
any
LICENCES HELD(IF ANY) N/A
Phone no +55 21 964880037
E mail address [email protected]
Skype address N/A
Date of Birth 14/07/1969
Place of Birth NOVA IGUAÇU - RJ

Attorney ( if you have one)


Address
Telephone
Fax
Mobile
Email Address

Origin Of Funds re this activity


Are Funds Free and Clear
Brief Corporate Activity

Facilitator and/or Intermediary for


transactions between groups and/or Buyers
and Sellers of:

Commodities/Banking
Instruments/Bonds/Currency Exchange

CLASSIFIED AND CONFIDENTIAL


Page 1 of 4
BANK NAME: ITAÚ

BANK ADDRESS: AV. MINISTRO ARY FRANCO 49 – BANGU RIO DE JANEIRO CEP:21862000

IBAN: BR43 6070 1190 0084 7000 0173 424C 1

SWIFT CODE: ITAUBRSP

BANK OFFICER:

BANK PHONE No:

BANK FAX No:

A/C NUMBER: 17342 - 4

EMAIL:

I hereby swear under penalty of perjury that the information given above is accurate and true.
Any information, work or service conducted hereunder is that of a private placement
transaction that is exempt from the Securities Act and not intended for the general public but
for Private Use Only.

___________________________________________________
SIGNATURE AND SEAL

Signatory: ADMILSON GOMES DE OLIVEIRA

Passport: FU534227

Country: BRASIL

Date: 05 NOV 2018

CLASSIFIED AND CONFIDENTIAL


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COPY OF BENEFICIARY PASSPORT.

CLASSIFIED AND CONFIDENTIAL


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PROOF OF RESIDENTIAL ADDRESS (Note that P.O.BOX is not acceptable)
To validate the home addresses of all parties, please provide at least ONE COPY of the following:
(a) Original and recent bank statement from a recognized bank
(b) Original and recent credit card statement
(c) Letter from your employer (on headed paper) confirming your permanent address
(d) Utility bill

CLASSIFIED AND CONFIDENTIAL


Page 4 of 4

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