Raiffeisen Bank S.A. Administra]ia Central` Pia]a Charles de Gaulle nr.

r. 15, sector 1, Bucure[ti Cod 011857 Romnia Telefon +40 21 306 1000
Fax +40 21 230 0700 E-mail: centrala@raiffeisen.ro www.raiffeisen.ro C.U.I. 361820 Num`r de \nregistrare \n Registrul Comer]ului J40/44/1991
Num`r de \nregistrare \n Registrul Bancar RB-PJR-40-009/1999 Cod de \nregistrare fiscal` RO361820 Capital Social 1.200 mil Lei
Societate administrat` n sistem dualist Cod BIC RZBRROBU Raiffeisen Direct: 0800 802 02 02 apel gratuit din re]eaua Romtelecom
Anexa 1 la F1- Cerere de \nscriere/actualizare date persoane juridice/entit`]i f`r` personalitate juridic`
Informa]ii privind beneficiarul real
Appendix 1 to the clients registration form for legal entities Information on the real beneficiary
*In cazul \n care clientul nu are alocat CUI, se va completa Codul de |nregistrare Fiscal`/ Should no URC be available,
the Fiscal Code will be provided
Declar`m c` / Declare that:
p persoanele identificate \n prezentul document de]in calitatea de beneficiar real al oric`rei tranzac]ii sau
opera]iuni ce se realizeaz` pe parcursul rela]iei de afaceri [i/sau ocazional` dintre Client [i Banc` / persons
identified in this document have the status of the real beneficiaries of any transaction, operations or activity that
are made during business relationship and / or occasionally between Client and Bank:
40024542
Denumire client / Client Name
Cod unic de \nregistrare (CUI)/ Unique Registration Code (URC)*
1. Nume
prenume/ Name,
Surname
Data na[terii/
Date of Birth
___ / ____ /________
Locul na[terii/
Place of Birth
Ceta]enie/
Nationality
Re[edin]a/
Residence
E-mail
Denumire angajator/
Employer name
CNP/ Personal
Identification
number
Domiciliul/
Domicile
Nr. Telefon/Fax /
Phone/Fax No
Ocupa]ia/
Occupation
|n cazul persoanelor fizice
nerezidente/ For non-resident
individuals:
Persoana expus` politic / Politically
exposed person
p DA/ YES p NU/ NO
|n caz afirmativ, se va bifa situa]ia
aplicabil` [i se vor completa
informa]iile solicitate/ If so, please
check the applicable situation and fill
in the requested information.
Func]ia public` important` de]inut`/ important public function held
___________________________________________________________________________
Membru direct al familiei dl/dnei/ direct family member of Mr./Mrs
_____________________________________, ce de]ine func]ia public` important`/
who holds significant public office ___________________________________________
Asociat al dl/dnei/ Associate with Mr. / Mrs. ___________________________ ce
de]ine func]ia public` important`/ who holds significant public office___________
2. Nume
prenume/ Name,
Surname
Data na[terii/
Date of Birth
___ / ____ /________
Locul na[terii/
Place of Birth
Ceta]enie/
Nationality
Re[edin]a/
Residence
E-mail
Denumire angajator/
Employer name
CNP/ Personal
Identification
number
Domiciliul/
Domicile
Nr. Telefon/Fax /
Phone/Fax No
Ocupa]ia/
Occupation
|n cazul persoanelor fizice
nerezidente/ For non-resident
individuals:
Persoana expus` politic/ Politically
exposed person
p DA/ YES p NU/ NO
|n caz afirmativ, se va bifa situa]ia
aplicabil` [i se vor completa
informa]iile solicitate / If so, please
check the applicable situation and fill
in the requested information.
Func]ia public` important` de]inut` / important public function held
___________________________________________________________________________
Membru direct al familiei dl/dnei / direct family member of Mr./Mrs
_____________________________________, ce de]ine func]ia public` important`/
who holds significant public office ___________________________________________
Asociat al dl/dnei / Associate with Mr. / Mrs. __________________________ ce
de]ine func]ia public` important` / who holds significant public office__________
p Nu exist` un beneficiar real, \n conformitate cu defini]ia legal`, deoarece / No real beneficiary, according to
legal definition, because:
Prin prezenta declar`m c` ne-a fost pus la dispozi]ie Ghidul de completare a formularelor pentru clien]i persoane
juridice / We hereby declare that a copy of the Legal Entities Forms Guide was made available to us.
3. Nume
prenume/ Name,
Surname
Data na[terii/
Date of Birth
___ / ____ /________
Locul na[terii/
Place of Birth
Ceta]enie/
Nationality
Re[edin]a/
Residence
E-mail
Denumire angajator/
Employer name
CNP/ Personal
Identification
number
Domiciliul/
Domicile
Nr. Telefon/Fax /
Phone/Fax No
Ocupa]ia/
Occupation
|n cazul persoanelor fizice
nerezidente/ For non-resident
individuals:
Persoana expus` politic/ Politically
exposed person
p DA/ YES p NU/ NO
|n caz afirmativ, se va bifa situa]ia
aplicabil` [i se vor completa
informa]iile solicitate / If so, please
check the applicable situation and fill
in the requested information.
Func]ia public` important` de]inut` / important public function held
___________________________________________________________________________
Membru direct al familiei dl/dnei / direct family member of Mr./Mrs
_____________________________________, ce de]ine func]ia public` important`/
who holds significant public office ___________________________________________
Asociat al dl/dnei / Associate with Mr. / Mrs. __________________________ ce
de]ine func]ia public` important` / who holds significant public office__________
Nume [i prenume reprezentant legal /
Legal Representative Name and Surname
Semn`tura Reprezentant Legal /
Legal Representative Signature
Data/
Date
niciun ac]ionar persoan` fizic` nu de]ine 25%+1 ac]iuni [i nu exist` nicio persoan` fizic` sau
grup de persoane fizice care s` controleze \n vreun mod organele de administrare / no
individual shareholder does have 25%+1 share and there is no person or group of individuals
in any way to control administrative bodies
societate/actionar majoritar (cel putin 75% din capital social) listat pe o piata reglementata /
company / shareholder (with minimum 75% of equity) listed on a regulated market
__________________________________________________________________
autoritati publice nationale/societati cu actionar majoritar statul / national public authorities /
companies with the State as main shareholder ______________________________________________
alte cazuri/ other cases ___________________________________________________________
p
p
p
p