Cozier & Associates
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COMPANY FORMATION AND ADMINISTRATION QUESTIONNAIRE

1. BENEFICIAL OWNERS - Full details are required for all beneficial owners. If these are privately owned companies or trusts, this information will be required for all of the ultimate beneficial owners/settlors thereof. All information will be treated as strictly confidential. We will be pleased to assist in the completion of this questionnaire.

a. FULL NAME:
RESIDENTIAL ADDRESS: NATIONALITY:______PERCENTAGE OF OWNERSHIP:
OCCUPATION:
TELEPHONE:______FAX:
SIGNATURE:
b. FULL NAME:
RESIDENTIAL ADDRESS
NATIONALITY:______PERCENTAGE OF OWNERSHIP:
OCCUPATION:
TELEPHONE:______FAX:
SIGNATURE: Additional beneficial owner details should be added to an attached sheet.

Have any of the beneficial owners, in any part of the world, been declared bankrupt or been a director or otherwise concerned in the management of a company which has been subject to an insolvent liquidation or a judicial inquiry?
(YES/NO) (If "Yes", please provide details on additional sheet)
PLEASE ENCLOSE COPY PASSPORT DETAILS FOR ALL BENEFICIAL OWNERS. (Duly Notarized)
2. INSTRUCTIONS - from whom may we accept further instructions relating to the Company (other than any one or more of the beneficial owners):
FULL NAME:
RESIDENTIAL ADDRESS:
TELEPHONE:______FAX:
Please provide specimen signature:

3. TIMING: - whilst every effort is made to proceed as quickly as possible, please advise any special timing requirements:
______

Please note that certain words in the company name may be restricted by government requirement or may attract a higher level of authorized share capital and related fee.

4. COMPANY NAME: - please provide two preferences, stating any special significance which may be attached to your choice:
(a)______
(b)______
5. OBJECTIVES - please outline the principal objectives and future activities of the company:
______
______
6. Will other beneficial owners be introduced within six months of incorporation? (If 'Yes,’ please provide the same details as in 1(a) above) YES/NO
7. REFERENCES - Please supply two references for each beneficial owner
Bank
1.
(Internationally known)
Professional
2.
(e.g. Lawyer or Accountant)
These will not necessarily be taken up by us but we reserve the right to do so if we deem it appropriate.

Additional information may be required when agreement to proceed has been given . Cozier & Associates will be pleased to offer detailed guidance with regard to any matters contained in this questionnaire.

I/We agree to abide by the terms and conditions as set out by Cozier & Associates and I declare that the information given herein is true and correct to the best of my /our knowledge.

______
Signature Signature

______
Witness

8. JURISDICTION - please confirm country in which the Company is to be: (a). formed:______(b).administered:

9. EXISTING COMPANY - if services are required for an existing, active company, please provide a history of the Company to date (preferably with copy minutes and statements of account) and advise below the reasons why the persons or entities providing the services are retiring:
______
______
______

10. SHARE CAPITAL - unless otherwise specified companies will be formed with the usual US$100, 000 authorized share capital, a par value of U.S.$1 per share and a nominal number of issued shares in registered/bearer form.
Shares can be registered in the names of nominees to avoid public disclosure of the names of beneficial owners.
Is there any intention to issue shares to the public? YES/NO
(If 'Yes', please provide full details)
______
______

11. SERVICES - please identify which of the following services are required:

(a) Arranging for the Incorporation or other formalities (including but not limited to change of name, transfer of management/ amendment of corporate documents) YES/NO

(b) Provision of a registered and/or administrative office YES/NO
(c) Provision of nominee shareholders YES/NO
(d) Provision of directors, alternate directors and/or officers including but not limited to the provision of a secretary of the Company YES/NO
(e) Maintenance of statutory books and records and the corporate seal and the submission of statutory or other returns YES/NO
(f) Arranging meetings of the directors and shareholders when required by law or in the general course of business YES/NO

(g) Maintenance of statutory books of account and the preparation of periodic statements of account based upon information received YES/NO

Preferred accounting year end date ______
Preferred accounting currency ______

Are accounts to be audited? YES/NO
(If 'Yes', please give details of your preferred auditors)
(h) Provision of banking facilities YES/NO
If 'yes' please answer the following:

(i) Preferred bank location ______

(ii) Account currency ______

(iii) Type of account cheque/deposit/investment
Please provide fullest details if alternative arrangements are to be made in respect of any of these services:
OTHER - please advise any other special requirements relating to the formation, acquisition or transfer of the Company:

FEES & EXPENSES AND TERMS & CONDITIONS - these will apply in all cases unless otherwise agreed in writing.

A minimum cash reserve of U.S.$2500 is required before any services can be undertaken. In exceptional circumstances other arrangements might be agreed upon, for example, an undertaking from a professional firm.

MANAGEMENT AND CONTROL - if full management services are to be provided, the Directors and Officers must maintain full control over the business activities and assets of the Company. This may prevent them from delegating authority, for example, by Power of Attorney, Contract, or other written authority.

Please note that contractual arrangements should not be made in relation to the company or the services to be provided without the prior consent of Cozier & Associates.
I/We agree to abide by the terms and conditions as set out by Cozier & Associates and declare that the information given herein is true and correct to the best of my/our knowledge.

Signature:
______

______

______Date:______