authorized person INFORMATION SHEET
Personal data collected through this Questionnaire will be processed for the purpose of customer due dilligence, in accordance with the Law on the Prevention of Money Laundering and the Financing of Terrorism and referent regulations.
Note: The Account Holder shall complete other type of the questionnaire.
INFORMATION ON THE AUTHORIZED PERSON:
First name, Last name: ______
Personal ID Number: ______Date of birth: ______
Place of birth: ______Country of birth: ______
Citizenship: ______Sex: ______
Residence (from the ID Document):
· Address: ______
· Town: ______
Code: BIB.1060.P.005-OBR.01 / Version: IV/12.09.2014 / Page 1 / 3/ Appendix No. 2
· Postal code: ______
· Country: ______
Code: BIB.1060.P.005-OBR.01 / Version: IV/12.09.2014 / Page 1 / 3/ Appendix No. 2
Domicile (if different from residence):
· Address: ______
· Town: ______
Code: BIB.1060.P.005-OBR.01 / Version: IV/12.09.2014 / Page 1 / 3/ Appendix No. 2
· Postal code: ______
· Country: ______
Code: BIB.1060.P.005-OBR.01 / Version: IV/12.09.2014 / Page 1 / 3/ Appendix No. 2
ID Document:
Code: BIB.1060.P.005-OBR.01 / Version: IV/12.09.2014 / Page 1 / 3/ Appendix No. 1
· Type: ______
· Number: ______
· Issuer: ______
· Date of release: ______
Code: BIB.1060.P.005-OBR.01 / Version: III/27.05.2013 / Page 2 / 4/ Appendix No. 1
Activity:
Code: BIB.1060.P.005-OBR.01 / Version: III/27.05.2013 / Page 2 / 4/ Appendix No. 1
· Employee
· Entrepreneur
· Freelancer
· Self-employed
· Unemployed
· Student
· Retired
· Other
Code: BIB.1060.P.005-OBR.01 / Version: III/27.05.2013 / Page 2 / 4/ Appendix No. 2
Additional information on the authorized person:
Have you or your close relative held at any time during last 12 months a public office, or have you been close associate of such person:
· In Serbia: YES NO
· In a foreign country or international organization: YES NO
Country where the main business is carried out: ______
INFORMATION ON THE ACCOUNT HOLDER:
Note: Person authorized for account disposal shall complete only name and personal ID number of the Account Holder.
First name, Last name: ______
Personal ID Number: ______Date of birth: ______
Place of birth: ______Country of birth: ______
Citizenship: ______Sex: ______
Residence (from the ID Document):
· Address: ______
· Town: ______
· Postal code: ______
· Country: ______
Domicile (if different from residence):
· Address: ______
· Town: ______
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 2 / 3/ Appendix No. 2
· Postal code: ______
· Country: ______
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 2 / 3/ Appendix No. 2
ID Document:
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 2 / 3/ Appendix No. 2
· Type: ______
· Number: ______
· Issuer: ______
· Date of release: ______
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 2 / 3/ Appendix No. 2
Phone:
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 2 / 3/ Appendix No. 2
· Home: ______
· Office: ______
· Cellular 1: ______
· Cellular 2: ______
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 3 / 3/ Appendix No. 2
E-mail address: ______
Activity:
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 3 / 3/ Appendix No. 2
· Employee
· Entrepreneur
· Freelancer
· Self-employed
· Unemployed
· Student
· Retired
· Other
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 3 / 3/ Appendix No. 2
Additional information on the Account Holder:
Has the Account Holder or his/her close relative held at any time during last 12 months a public office, or has he/she been close associate of such person:
· In Serbia: YES NO
· In a foreign country or international organization: YES NO
Country where the main business is carried out: ______
Type of transactions that will be processed through the account:
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 3 / 3/ Appendix No. 2
· Cash transactions
· Cross-border transactions
· Wire transactions
· Savings and investments
Code: BIB.1060.P.005-OBR.02 / Version: IV/12.09.2014 / Page 3 / 3/ Appendix No. 1
· Other: ______
Will the turnover on the account mostly refer to cash transactions? If YES, please explain the reasons and specify the expected average amounts (roughly):
______
Please specify the expected average level of in-payments to the account:
Code: BIB.1060.P.005-OBR.01 / Version: III/27.05.2013 / Page 3 / 3/ Appendix No. 1
· Up to 1,000 Euros monthly
· Up to 2,000 Euros monthly
· Up to 4,000 Euros monthly
· Up to 10,000 Euros monthly
· Over 10,000 Euros monthly
Code: BIB.1060.P.005-OBR.01 / Version: III/27.05.2013 / Page 3 / 3/ Appendix No. 2
What are the expected sources of funds:
· Regular salary
· Other (please specify): ______
Annual amount of expected other income: ______
Will the transactions on behalf of third persons be carried out through the account? YES NO
Hereby I confirm that all data given in this document are true and I am in full agreement with the Bank's right to check them. I will promptly inform the Bank on any change regarding the data given above.
Hereby I am giving lawful consent for processing of personal data given in this document, including but not limited to the particularly sensitive data. This consent is valid until revoked. I also declare that the Bank informed me on the possibility to check all details on the manner of processing the said data in the Central Data File Register maintained by the Commissioner for Information of Public Importance and Personal Data Protection, at the Web address: http://registar.poverenik.rs.
______, ______
Place and date Authorized Person's signature
Code: BIB.1060.P.005-OBR.02 / Version: III/27.05.2013 / Page 4 / 4