Account No.

CLIENT PROFILE / ECONOMIC BACKGROUND

Account name:

Beneficial Owner

(only if different from account name)

Choose a box: New client profile Update of client profile

Reason for update:

Type of account:

Personal Commercial company Offshore company

Other (fund, trust, foundation):

Offshore company: Are reputed offshore companies, irrespective of their object, their legal form and their head office, Swiss or foreign companies
which do not have their own premises (head office with a lawyer, fiduciary company, bank, etc.) or which do not employ staff exclusively working for
them, or whose own staff only does administrative tasks (bookkeeping, and correspondence upon instructions from individuals or companies
heading the offshore company).

Referrer:
The client is referred by:

An account manager: name:

An existing client: account no:

An authorized third party (IAM) name:

Walk-in client

Relationship between the client and the initiator:

The referrer has known the client since:

 Beneficial Owner No 1 Cocontracting Party
(give information on Beneficial Owner, settler, founder, or on shareholders owning 20% or more in the company):

Personal data:

Name and Surname:

Date and place of birth (or incorporation):

Legal domicile:

Residence:

Family situation (If married, name of spouse):

Nationality:

Telephone No. (private/business):

Fax (private/business):

E-mail :

Professional data:

Describe the client's present occupation as well as his previous activities, his position or function, training, qualifications, information on
his business partners, products and services, suppliers and clients:

Name of client's business:

Address of client's business:

Country of business

Size of business (number of employees, annual turnover, etc ):

Has the business office been visited? yes no

Source of funds:

Details regarding the source of assets (savings, inheritance, family wealth, revenues from activity) :

Client's financial surface:

up to 1 mio up to 2 mio up to 5 mio up to 10 mio higher

Estimated annual revenues:

Other relationships/tied accounts:

Does the Beneficial Owner have other accounts? no if so, indicate account numbers:

Does the Beneficial Owner share a relationship no if so, indicate account numbers and
with other clients? type of relationship:
 Beneficial Owner No 2 Cocontracting Party
(give information on Beneficial Owner, settler, founder, or on shareholders owning 20% or more in the company):

Personal data:

Name and Surname:

Date and place of birth (or incorporation):

Legal domicile:

Residence:

Family situation (If married, name of spouse):

Nationality:

Telephone No. (private/business):

Fax (private/business):

E-mail :

Professional data:

Describe the client's present occupation as well as his previous activities, his position or function, training, qualifications, information on
his business partners, products and services, suppliers and clients:

Name of client's business:

Address of client's business:

Country of business

Size of business (number of employees, annual turnover, etc ):

Has the business office been visited? yes no

Source of funds:

Details regarding the source of assets (savings, inheritance, family wealth, revenues from activity) :

Client's financial surface:

up to 1 mio up to 2 mio up to 5 mio up to 10 mio higher

Estimated annual revenues:

Other relationships/tied accounts:

Does the Beneficial Owner have other accounts? no if so, indicate account numbers:

Does the Beneficial Owner share a relationship no if so, indicate account numbers and
with other clients? type of relationship:
 Beneficial Owner No 3 Cocontracting Party
(give information on Beneficial Owner, settler, founder, or on shareholders owning 20% or more in the company):

Personal data:

Name and Surname:

Date and place of birth (or incorporation):

Legal domicile:

Residence:

Family situation (If married, name of spouse):

Nationality:

Telephone No. (private/business):

Fax (private/business):

E-mail :

Professional data:

Describe the client's present occupation as well as his previous activities, his position or function, training, qualifications, information on
his business partners, products and services, suppliers and clients:

Name of client's business:

Address of client's business:

Country of business

Size of business (number of employees, annual turnover, etc ):

Has the business office been visited? yes no

Source of funds:

Details regarding the source of assets (savings, inheritance, family wealth, revenues from activity) :

Client's financial surface:

up to 1 mio up to 2 mio up to 5 mio up to 10 mio higher

Estimated annual revenues:

Other relationships/tied accounts:

Does the Beneficial Owner have other accounts? no if so, indicate account numbers:

Does the Beneficial Owner share a relationship no if so, indicate account numbers and
with other clients? type of relationship:
Information regarding the account and its future activity:

Objectives of the account: Private banking Business Other:

Should the client/beneficial owner already have an account open with us, explain the purpose of this new account:

Activity and estimated size of the account:

Estimated time schedule to reach this amount:

12 months 1 to 2 years Over 2 years

Expected activities: Cash transactions amounts/frequency:

Credit card Cheques amounts/frequency:

Travel Cash Card Bank transfers amounts/frequency:

Investments/deposits

Source and description of the initial funds expected within 1 to 3 months' time:

bank transfer Approx. amount: from (bank, place):

Bank cheque Approx. amount: issued by:

Cash deposit Approx. amount: reason :

Securities deposit Approx. amount: from (bank, place):

Remarks:

To be filled out only for business accounts

Estimated average balance:

Expected assets within the first 12 months:

Annual volume expected (indicate the currency): IN: /OUT:

Expected annual number of transfers: IN: /OUT:

Source of incoming funds:

OWN ACCOUNTS CBH, Julius Bar, HSBC

Source of outgoing funds:

 Power of Attorney Right of Examination Credit Card Holder Travel Cash Card Holder

Full name (family name in capital letters):

Date and place of birth (or incorporation):

Legal Domicile:

Residence:

Nationality:

Telephone:

E-mail:

Relationship between the Beneficial Owner and Holder of Power of Attorney:

Business information:

Describe the client's present occupation as well as his previous activities, his position or function, training, qualifications information on his business partners,
products and services, suppliers and clients:

Power of Attorney 2 Right of Examination Credit Card Holder Travel Cash Card Holder

Full name (family name in capital letters):

Date and place of birth (or incorporation):

Legal Domicile:

Residence:

Nationality:

Telephone:

E-mail:

Relationship between the Beneficial Owner and Holder of Power of Attorney:

Business information:

Describe the client's present occupation as well as his previous activities, his position or function, training, qualifications information on his business partners,
products and services, suppliers and clients:

Power of Attorney 3 Right of Examination Credit Card Holder Travel Cash Card Holder

Full name (family name in capital letters):

Date and place of birth (or incorporation):

Legal Domicile:

Residence:

Nationality:

Telephone:

E-mail:

Relationship between the Beneficial Owner and Holder of Power of Attorney:

Business information:

Describe the client's present occupation as well as his previous activities, his position or function, training, qualifications information on his business partners,
products and services, suppliers and clients:
Signatures

Should the client be considered "at risk" or as a PEP? yes no

Indicate the reason:

I know this individual/company very well and I recommend him/it as a potential client for the Bank.

I do not know very well this individual/company; however, I can recommend him/it as a potential client for the Bank, in view of the
above referral.

Remark:

Initials, signature Account Manager 1: de Beaumont Account Manager 2:

Form filled out by: Date:

To be filled out by compliance:

Compliance controls World-check Lexis-Nexis Other

Remark:

Should the client be considered "at risk" or as a PEP? yes no

Initials and signature of Compliance Officer : Date :

If the account is "at risk", signature of a member of General Management:

Date :

For clients " at risk" and PEP, date of approval by the Due Diligence Committee:
 Beneficial Owner No 1 Cocontracting party

Professional data:

Source of funds: