Customer identification form
(To be filled by the customer, and if the customer is a corporation – by its authorized signatory, representative or a person holding a letter of appointment to act on behalf of the corporation)
Part A
Registration of the identification details of an individual
Name of the customer: ______
Identification number and country of issue: ______
Date of birth: ______
Sex: ______
Address: ______
Registration of the identification details of the corporation
Name of corporation: ______
Corporation registration number: ______
Date of incorporation: ______
Address: ______
Country of incorporation: ______
Controlling shareholders in the corporation[1]:
Name / Identification No.______/ s______
______/ ______
Know the customer - for the purpose of performing one of the actions specified hereunder by the DNFBP:
Occupation of the customer: ______
A customer that owns a business – type of business: ______
Purpose of providing the business service: ______
Source of the funds used for the business service: ______
Type of the business service planned to be performed for the customer by the DNFBP:
Buying, selling or long term lease of immovable property
Detailed description of the activity: ______
Details of the transaction (including details of the property, the possessor of the property, owner of the property and beneficiary in the property, the parties to the transaction): ______
Buying or selling of a business
Detailed description of the activity: ______
Details of the transaction (including details of the business, senior officers in the business, the parties to the transaction): ______
Managing the assets of the corporation, including financial management, securities and immovable property, and managing the accounts of a customer in a banking corporation or a stock exchange member, portfolio manager, insurance company and insurance agent, a management company of a provident fund or the Postal Bank.
Detailed description of the activity: ______
Details of the assets that are managed (including their financial scope, location, other right holders in the property, representatives in connection with the managed assets, beneficiaries in the assets): ______
Receiving, possessing or transferring funds for the purpose of establishing or managing a corporation
Detailed description of the activity: ______
Details of the funds (including their financial scope) and details about the corporation (name of corporation, corporation registration number, date of incorporation and country of incorporation, controlling shareholders in the corporation1, purpose of the activity in the corporation and expected scope of financial activity): ______
Establishment or management of a corporation, business or trust to another
Detailed description of the activity: ______
[In a corporation: the name of the corporation, corporation registration number, date of incorporation and country of incorporation, controlling shareholders in the corporation1, object of the corporation and the expected scope of financial activity.
In a business: the name of the business, business registration number (if any), senior officers in the business, object of the business and expected scope of financial activity.
In a trust: name of the trust, place of establishment of the trust, object of the trust, type of trust, location of the assets of the trust, scope of financial activity in the trust, trustees, creator of the trust, protector (the entity giving instructions) and beneficiaries in the trust.]
Is the business service provided for another?Yes
If the business service provided for another – write down his details:
For a person:
Name ______ID. No./Passport No. ______, country of issue______date of birth ______, address______and sex______.
Name of corporation ______, corporation registration number ______, date of incorporation and country of incorporation ______, controlling shareholders in the corporation[2] ______, spheres of activity of the corporation ______
If the identity of the beneficiary is not known:
I declare that the identity of the beneficiary is not known at the time and I undertake to provide the full details of the beneficiary as specified above immediately upon becoming aware of them.
Signature: ______
Inquiry of a politically exposed person
(1)What is your relation to Israel? ______
(2)Are you a foreign resident?
Yes
No
If the answer is yes, do you hold a senior public office abroad as specified hereunder (including an office as said even if bearing a different title)? (Please check):
I do not hold a senior office abroad
Head of state
President of state
Mayor
Judge
Member of parliament
Member of government
Senior military officer
Senior police officer
Another senior public office ______(please specify)
(3)Do you have a family member (spouse, and a sibling, parent, parent of a parent, a child or a child of the spouse, or the spouse of any of the above) who holds senior public office abroad?
Yes
No
If the answer is yes, please specify his name according to the list specified in Section 2 above: ______
(4)Do you act in the name of the corporation?
Yes
No
If the answer is yes, does one of the controlling shareholders in the corporation hold a senior public office abroad (including such a position as said even if bearing a different title)?
Yes
No
If the answer is yes, please indicate his office according to the list specified in Section 2 above: ______
(5)Are you a business partner of a foreign resident?
Yes
No
If the answer is yes, does the business partner hold a senior public office abroad (including an office as said even if its title is different)?
Yes
No
If the answer is yes, please indicate his position in accordance with the list provided in Section 2 above: ______.
Politically Exposed Person
- What is your relation to Israel?
- Are you a foreign resident?
Yes
No
If the answer is yes, do you hold a senior public position in a foreign country? Please select a job title below that best describes your occupation:
I do not hold a senior public position in a foreign country
Head of State
President of a Country
Mayor
Judge
Member of Parliament
Member of Government
Senior Military Officer
Senior Police Officer
Other Senior Public Position: (please specify)
- Do you have a family member (spouse, sibling, parent, grandparent, child, stepchild, or spouse of any of the above) who holds a senior public position in a foreign country?
Yes
No
If the answer is yes, please write the job title that best describes his/her occupation from the list in Article 2 above:
- Are you acting on behalf of a corporation?
Yes
No
If the answer is yes, does one of the controlling shareholders of the holds a senior public position in a foreign country as described below?
Yes
No
If the answer is yes, please write the job title that best describes his/her occupation from the list in Article 2 above:
- Are you a business associate/partner of a foreign resident?
Yes
No
If the answer is yes, Does this business associate holds a senior public position in a foreign country as described below?
Yes
No
If the answer is yes, please write the job title that best describes his/her occupation from the list in Article 2 above:
Declaration of the customer filling the form
I hereby declare that the details specified above were noted by me and they are true and accurate to the best of my knowledge. If any change occurs in these details, I undertake to notify about such change at the earliest opportunity. If it becomes apparent that the information specified above is false or misleading, I am aware that I may be held liable in respect whereof.
I agree and I am aware that the advocate/auditor shall keep a copy of this form for the periods specified in Section 8 of the Order.
Date______
Signature of customer______
Part B:
Confirmation of performance of identification
For face to face identification (section 6):
I confirm that on ______a customer by the name of ______who identified himself before me with ID. No. ______a copy of which is hereby enclosed appeared before me and signed this form before me.
Name of the person performing the identification: ______ID. No. ______Signature______
In identification other than face to face (section 7):
I certify that on ______I identified the customer signed on this form in the name ______ID. No. ______who identified himself with ______a copy of which is hereby enclosed.
Name of the person performing the identification ______ID. No. ______Signature______
Confirmation of the DNFBP regarding examination of information regarding customer identification
(To be filled by the DNFBP)
I certify that on ______I examined the details that were provided in accordance with the form enclosed in the First Schedule and I acted in accordance with the said in Section 2(c) of the Order.
Name ______ID. No. ______Signature ______
[1] Regarding a controlling shareholder that is a corporation, fill in the name of the controlling shareholders (who are persons) of a controlling shareholder that is a corporation.
[2]