Know Your Customer Form

For Individuals only

For Bank use only

BRANCH CUSTOMER IDENTIFICATION NUMBER
Hastings Ch. Ch.

PLEASE COMPLETE THE FORM IN ITS ENTIRETY IN BLOCK LETTERS ONLY

▪ To comply with our obligations as a regulated Financial Institution we are mandated to request the information contained therein.
▪ A separate Know Your Customer (KYC) form should be completed for additional joint holders.

1. Identity Information
Prefix First Name Middle Name Last Name

Applicant Name

Former Name

Date of Birth Gender M  F 

(dd/mm/yyyy)

Marital Status Single  Married  Divorced  Widowed  Common law 

Nationality

Are you a citizen/ resident of any other country? Yes ☐ No ☐

If Yes, please state

2. Proof of Identity

Passport # PP Expiration Date

National ID Card # ID Expiration Date

Driver’s License # DL Expiration Date

Other Expiration Date

3. Address Information
a. Residential/ Permanent Address

Address Line 1

Address Line 2

Address Line 3

Country

b. Residential/ Permanent Address (Last 3 years)

Address Line 1

Address Line 2

Address Line 3

Country

4. Contact Information

Home Tel # Mobile #

Work # Email

FORM # GRC-001 Page 1 of 4

 5. Expected Source of Funds through Accounts

Salary  Pension  Interest/ Dividends  Other 

Rental Income  NIS payment  Gratuity 

Expected Monthly Transaction Volume (Loan Payments) $___________________ /month __________ transactions/ month

Expected Monthly Transaction Volume (Foreign Exchange) $___________________ /month ____________ transactions/ month

Expected Total Term Deposit Balance $________________________

Total Monthly Transaction Volume $_______________ /month total ______transactions/ month in total

6. Employment Information

Employment Status Salaried worker  Retiree  Unemployed 

Self-employed  Student 

Occupation

Job Title

Industry Length of Service

Occupation Type Professional  Supervisor  Senior executive 

Skilled worker  Middle Management 

Mthly Income Range

(from all sources)

Employer

Employer’s Address

7. 1PEP (Politically Exposed Person) Attestation (tick where applicable to you)

Yes No
a. Have you ever been a Head of State or Head of Government, a Senior Politician, a Senior Government  
Official, a Senior Judicial, Military or Law Enforcement Official, a Member of the Board of Central Bank
or similar regulator, an Ambassador or a charge d/affaires, either local or foreign?

If yes, please provide details

b. Have you ever been a senior official of a major Political Party or a senior executive of a local or foreign  
Government owned commercial enterprise, either local or foreign?

If yes, please provide details

c. Are you an immediate family member (spouse, parent, sibling, child) or close personal or professional  
associate of anyone in the above categories (a – b)?

If yes, please provide details

 
d. Have you ever been entrusted with a prominent function by an international organization either local or
foreign?

If yes, please provide details

8. Purpose of Business Relationship

Please indicate the banking products which relates to you

Fixed Deposit Account  Vehicle Loan  Commercial Loan 

Mutual Fund Account  Mortgage Loan  Lease 

Foreign Exchange  Consumer Loan 

1
A PEP is defined by the Financial Action Task Force (FATF) as “an individual who is or has been entrusted with a prominent public function.” The
FATF recognizes that, due to their status and influence, many PEPs are in positions that can be platforms for committing money laundering and
related predicate offences. These include corrupt practices and bribery, as well as conducting activities related to the financing of terrorism.
FORM # GRC-001 Page 2 of 4
 9. Connected Party Information
a. Are you a major shareholder, partner or director in a business entity that is an existing customer of Consolidated
Finance Co. Limited? Yes  No 

If yes, please indicate company

b. Are you a Director/ Officer of any company in the Ansa McAl Group? Yes  No 

If yes, please indicate company

c. Are you a spouse (including common law), parent, sibling, child or spouse’s child of a Director/ Officer of any
company in the Ansa McAl Group Yes  No 

If yes, please provide details

10. Customer Declaration & Consent

I declare that the information furnished by me to / Consolidated Finance Co. Limited (CFC) is true and correct and CFC is entitled
to verify the same either directly or through any third-party agent. I also agree that, if any such declarations made by me are
found to be incorrect, CFC shall be entitled to terminate the account relationship. I confirm having read and understood the
account rules of CFC, and hereby agree to be bound by the terms and conditions and amendments governing the account(s)
issued by CFC from time to time.

I also agree that CFC can disclose this application, any information contained therein, other related confidential information and
transactions in this application and on accounts linked to me to law enforcement and regulatory authorities.

Account holder name

Date

Specimen Signature

FORM # GRC-001 Page 3 of 4

 11. For Bank Purposes Only
1.
 PROSPECTIVE CUSTOMER  EXISTING CUSTOMER  US/ CRS CUSTOMER
(Initial Screening) (Retrospective Screening)

2. AML/CFT Risk rating (please tick appropriate box)

 HIGH RISK  MEDIUM RISK

Please indicate which applies Please indicate which applies

 POLITICALLY EXPOSED PERSON  FORMAL WORKER
 INTRODUCED BUSINESS  ANSA MCAL STAFF
 FOREIGN RESIDENT a  PENSIONER
 ESTATE EXECUTOR / ADMINISTRATOR  STUDENT/ MINOR.
 POWER OF ATTORNEY
 REAL ESTATE AGENT b
 LAWYER c
 ACCOUNTANT c
 NOTARY c

a. Refers to foreign clients not domiciled in Barbados or with limited financial history
b. Refers to agents involved in the buying and selling of real estate
c. Refers to sole practitioners, partners and employed professional within professional firms. It is not meant to
refer to internal professional who are employees of other types of business, or to professionals working for
government agencies who may already be subject to measures that would combat money laundering.

3. Has customer identity been verified in line with required standards & true copies of documents obtained?
Yes ☐ No ☐

Department unit

Transaction Officer
(NAME IN BLOCK LETTERS)

Officer’s Signature Date

Manager
(NAME IN BLOCK LETTERS)

Manager’s Signature Date

Client [ ]
screened High Risk – Snr
Compliance Validity Yy/mm/dd Mgmt. review [ ]
(NAME IN BLOCK LETTERS)

Signature Date

FORM # GRC-001 Page 4 of 4