E-mail: info@b2b-bank.com
Phone: +1 784 482 9656
Fax: +1 784 482 9656
www.b2b-bank.com
B2B Bank Limited
Suite A, 2nd Floor
St. Clair Investments Arnos Vale Building
Box 2043, Kingstown VC0100
St. Vincent and the Grenadines
PERSONAL ACCOUNT & SERVICE
APPLICATION & MAINTENANCE FORM
Please write in BLOCK CAPITALS and check “X” where necessary
CUSTOMER INFORMATION
New account
Maintenance
Title & Name, Surname: [Title]
Date of birth:
Nationality/Country of birth:
Passport / Identification document:
(No., Authority, date and place of issue, date of expiry)
Permanent residential address (NB – P.O. Box numbers and
c/o addresses, temporary addresses are NOT acceptable):
CONTACT INFORMATION
Telephone:
Fax:
E-mail:
Mailing address (address for correspondence):
Language of communication:
English
Russian
French
Other:
Preferred means of communication:
Online Banking
Phone
E-mail
JOINT OWNERS / AUTHORIZED SIGNATORIES
Authorized Signatory / Joint owner
Authorized Signatory / Joint owner
CIF#
CIF#
Authorized Signatory / Joint owner
CIF#
Title & Name, Surname
Date of birth
Passport or ID details (No.,
Authority, date and place of issue,
date of expiry)
Nationality
Registered address / Mailing
address
Phone & E-mail address
Relationship
Employee
Occupation
Business owner
Employee
Business owner
Employee
Officer of state or municipal authority
Officer of state or municipal authority
Self -employed
Self -employed
Self -employed
Retired
Retired
Retired
Other:
Other:
Other:
B2B Bank Limited / SWIFT: BTBBVCVC
APL.09P/V02/Approved at 12.03.2015
CONFIDENTIAL The B2B Bank logo is a trademark of B2B Bank Limited, used by B2B-Bank under license.
[Title]
Business owner
Officer of state or municipal authority
Page 1 of 4
PERSONAL ACCOUNT & SERVICE
APPLICATION & MAINTENANCE FORM
Place of work / Position
Annual personal income &
Source of income /wealth
Have you ever been discharged bankrupt?
Yes
Have you ever been discharged bankrupt?
No
Yes
Have you ever been convicted of a criminal
offence involving fraud and dishonesty?
Yes
Declaration:
Have you ever been convicted of a criminal
offence involving fraud and dishonesty?
No
Yes
Have you ever been the subject of a judicial or
other inquiry?
Yes
No
Have you ever been the subject of a judicial or
other inquiry?
No
Yes
Are you or your close relatives classified as
politically exposed persons*?
Yes
No
No
Are you or your close relatives classified as
politically exposed persons*?
No
Yes
If ‘Yes’ to any of these questions, give details:
No
If ‘Yes’ to any of these questions, give details:
Have you ever been discharged bankrupt?
Yes
No
Have you ever been convicted of a criminal
offence involving fraud and dishonesty?
Yes
No
Have you ever been the subject of a judicial or
other inquiry?
Yes
No
Are you or your close relatives classified as
politically exposed persons*?
Yes
No
If ‘Yes’ to any of these questions, give details:
*Politically exposed person: a person in prominent public function or closely related to such a person (eg.Senior Government/Political/Military/Judicial/Corporate position).
INFORMATION ABOUT CUSTOMER ACTIVITIES
Occupation:
Employee
Officer of state or municipal authority
Business owner
Self -employed
Retired
Other:
Additional comments if required:
Nature of Employment/Business:
Company / Institution name
Company / Institution address
Main business areas
Position
Number of years with current employer
Additional comments if required:
INFORMATION ABOUT CUSTOMER FINANCIAL ACTIVITIES
Purpose of Account:
saving and expending for personal needs
buying or selling real estate
salary payments
buying or selling companies shares
investing
other:
Additional comments if required:
Source and/or introduction of account:
authorized overseas representative
Bank’s Officer
business partners
choice of services and service quality
agent (please specify the agent):
other:
B2B Bank Limited / SWIFT: BTBBVCVC
APL.09P/V02/Approved at 12.03.2015
CONFIDENTIAL The B2B Bank logo is a trademark of B2B Bank Limited, used by B2B-Bank under license.
[Title]
Page 2 of 4
PERSONAL ACCOUNT & SERVICE
APPLICATION & MAINTENANCE FORM
Source of Income / Wealth:
salary
royalties / rewards
interest receivable and dividends
Income received from:
capital share (stocks) sale
private property sale
inheritance/gifts
rent
other (specify in detail):
Products/services of the B2B Bank Ltd you are planning to use:
transfers
savings accounts
currency exchange deposits
credit facilities
deposits
payment cards
other:
Additional comments if required:
Account currency* applied for/maintained**:
USD
EUR
GBP
JPY
AUD
CHF
CAD
HKD
RUB
Other:
Additional comments if required:
*Note that the default currency is United States Dollars (USD). The accounts can be set up as a multi-currency account.
**Subject to the current offer of the Bank. For actual information please contact your Personal Banker.
Initial deposit detail (amount, currency and source):
Estimated number of incoming transfers (credits) per month:
Estimated number of outgoing transfers (debits) per month:
Estimated monthly average account turnover (USD):
Estimated monthly average account turnover (EUR):
Estimated monthly average account turnover (other):
Estimated monthly average account turnover (other):
Additional documents and information that customer can submit to the bank:
proof of employment
sale and purchase agreement
employment contract
loan agreement
documents confirming inheritance
description of customer’s business before account opening
income statement
other:
Additional comments if required:
Do you request regular account statement to be sent to you?
Type and frequency of receiving statement:
By courier*
By post*
Once a month
Online Banking
No
Yes:
Via e-mail:
Once a quarter
Do not send regular current account statement if there is no funds movement on a current account.
Language of the statement:
English
Russian
Additional comments if required:
*You can print your account statements using online banking. Should you choose to have us mail statements, then a nominal fee will apply (in accordance with Bank’s Fees and Charges).
Do you have accounts with other banks?
No
Yes: names of the banks:
Additional comments if required:
B2B Bank Limited / SWIFT: BTBBVCVC
APL.09P/V02/Approved at 12.03.2015
CONFIDENTIAL The B2B Bank logo is a trademark of B2B Bank Limited, used by B2B-Bank under license.
[Title]
Page 3 of 4
PERSONAL ACCOUNT & SERVICE
APPLICATION & MAINTENANCE FORM
This account will be used for
my (our) behalf
on behalf of a third party. Information on the beneficial owner(s) is attached.
Additional comments if required:
DECLARATION
I declare that:
(a) I have received, read, understood and accept B2B Bank Limited’s General Terms and Conditions of Services and applicable Fees and Charges
(available on Bank’s website www.b2b-bank.com) and confirm that I was informed of and agree to the data protection and privacy statement
contained in the B2B Bank’s General Terms and Conditions of Services.
(b) I am not involved in any criminal, money-laundering or terrorist activity and the funds that are and will be held on my B2B Bank Limited account,
are not derived from any illegal activities, and all monies deposited to the account are and will be beneficially owned by me and used for the
purpose disclosed in this application;
(c) I do not have citizenship or equivalent tax obligation status for the United States of America;
(d) I do not reside in nor am I a resident of St. Vincent and the Grenadines;
(e) The information given is correct and complete;
(f) I will promptly notify the Bank in writing of any change of information; and
(g) I authorize the Bank to obtain independent confirmation of all information provided by me.
Customer /Joint owner(s) / Authorized Signatory(ies) :
(1)
(2)
Name, Surname
Signature ________________________
(2) Name, Surname
Signature ________________________
(3)
Signature ________________________
Name, Surname
(4)
Signed at
this day
of
20
TO BE COMPLETED BY THE BANK
ACCOUNT NUMBER
FOR BANK USE ONLY:
CIF #
Signature(s) of the above mentioned person(s) is/are hereby certified by:
Name of the officer: ____________________________________________
Date: __________________
Signature: _________________________
Application package received and verified as complete (remote representative) by:
Name of the officer: ____________________________________________
Date: __________________
Signature: _________________________
Bank’s notes: _________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
B2B Bank Limited / SWIFT: BTBBVCVC
APL.09P/V02/Approved at 12.03.2015
CONFIDENTIAL The B2B Bank logo is a trademark of B2B Bank Limited, used by B2B-Bank under license.
[Title]
Page 4 of 4