Customer Registration Form Formato de Registro Persona Natural

Customer Registration Form
Formato de Registro Persona Natural
General Info / Datos Generales
Last Name / Primer Apellido
Mother's Maiden Name / Segundo Apellido
First Name / Primer Nombre
Middle Name / Segundo Nombre
Date of Birth / Fecha de Nacimiento
Passport Number / Pasaporte
Contry of Birth / País de Nacimiento
Country of Residency / Pais de Residencia
Nacionality / Nacionalidad
Principal Activity / Actividad Principal
Secundary Activity / Actividad Secundaria
Gender / Sexo
Marital Status / Estado Civil
Home Status / Tipo de Vivienda (i.e. owned,rented) School Level / Nivel de Educación
Profession / Profesión
Source of Income / Fuentes de Ingreso
Address / Direccion
Home Address / Direccion de Hogar
Street Address / Calle o Avenida
Apt. Number / Casa o Apartamento
City / Ciudad and/ y County / Municipio
State/ Estado o Provincia
Country / Pais
ZIP Code / Zona Postal
Mailing Address / Direccion de Correspondencia
Street Address / Calle o Avenida
Apt. Number / Casa o Apartamento
City / Ciudad and/ y County / Municipio
State/ Estado o Provincia
Country / Pais
ZIP Code / Zona Postal
Page 1
Telephone / Telefonos
Home Phone / Telefono de Habitacion
Cell Phone / Telefono Celular
(+ Contry Code - Area Code - Phone Number)
(+ Contry Code - Area Code - Phone Number)
Office Phone / Telefono de Trabajo
Fax Number / Numero de Fax
(+ Contry Code - Area Code - Phone Number)
(+ Contry Code - Area Code - Phone Number)
e-Mail Address / Direccion de e-Mail
Home Address / Direccion Personal
Work Address / Direccion de Trabajo
Note: This e-mail address will be use for all comunications with the Bank, please make sure that you update this information
Nota: Esta direccion de e-mail sera utilizada para todas las comunicaciones que el Banco le envie, por favor mantengala
actualizada.
Products / Productos
Select all the Products to be activated / Seleccione los productos a ser activados
Advanced Checking Account
EZ Personal Savings
Bonus Savings
Accelerated Money Market
Euro Personal Account
CD Plus
Requisites / Requisitos
* Comply with minimum amount per product / Cumplir con el monto mínimo de apertura
* Account Opening Form / Formato de Apertura
* Source of Funds Declaration Form / Planilla de Procedencia de Fondos
* 2 Signature Cards / 2 Tarjetas de firmas
* An original Bank Reference indicating the average amount managed in the account and years
of activity / Una Referencia Bancaria en original, indicando antigüedad y los promedios
manejados en la cuenta
* Copy of valid ID and Passport from all authorized signatures /Copia del Documento de
Identidad y Pasaporte vigente y legible para todas las firmas autorizadas
* Proof of Residency (Utility Invoice) / Prueba de Residencia (Recibo de Servicio Publico)
Page 2
Authorized Signatures / Firmas Autorizadas
Number of Authorized Signatures
/ No. De Firmas Autorizadas :
Signatures Protocol / Protocolo de Firmas:
Joint / Conjuntas ____
Individual / Indistintas ____
Authorized Signature 1:
Fingerprint (Right Thumb)
Name:
Authorized Signature 2:
Fingerprint (Right Thumb)
Name:
Authorized Signature 3:
Fingerprint (Right Thumb)
Name:
Authorized Signature 4:
Fingerprint (Right Thumb)
Name:
AFFIDAVIT:
We hereby confirm that the information shown above confirms the identity of the Authorized Signatures. Furthermore, I will
inform Commonwealth Bank on a timely matter of any change concerning the information described above.
Confirmo que se ha cumplido, en todo lo posible, con la revisión de la identidad del/los arriba mencionado(s) firmante(s).
Además, me comprometo a informar a Commonwealth Bank sin demora sobre cualquier cambio concerniente con la
identidad de dicho(s) firmante(s).
Page 3
Authorized Signatures / Firmas Autorizadas
Number of Authorized Signatures
/ No. De Firmas Autorizadas :
Signatures Protocol / Protocolo de Firmas:
Joint / Conjuntas ____
Individual / Indistintas ____
Authorized Signature 1:
Fingerprint (Right Thumb)
Name:
Authorized Signature 2:
Fingerprint (Right Thumb)
Name:
Authorized Signature 3:
Fingerprint (Right Thumb)
Name:
Authorized Signature 4:
Fingerprint (Right Thumb)
Name:
AFFIDAVIT:
We hereby confirm that the information shown above confirms the identity of the Authorized Signatures. Furthermore, I will
inform Commonwealth Bank on a timely matter of any change concerning the information described above.
Confirmo que se ha cumplido, en todo lo posible, con la revisión de la identidad del/los arriba mencionado(s) firmante(s).
Además, me comprometo a informar a Commonwealth Bank sin demora sobre cualquier cambio concerniente con la
identidad de dicho(s) firmante(s).
Page 4
ORIGIN OF FUNDS / ORIGEN - PROCEDENCIA DE FONDOS
I ___________________________________________, hereby declare that the amount of
___________________ US$
EUR€
to be deposited on the Account open wit
Commonwealth Bank has been obtained by me from the following activity:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Yo, ________________________________________, declaro por el presente que la cantidad
EUR€
total de US$
________________, a ser depositada en la cuenta abierta con
Commonwealth Bank, representa fondos obtenidos por mi los cuales proceden de la siguiente
actividad:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
USAGE OF FUNDS / DESTINO - APLICACION DE FONDOS
I___________________________________________, hereby declare that the funds in US$
or EUR€
to be debited from the Account open with Commonwealth Bank will be used
for the following activity:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Yo, _______________________________________, declaro que los fondos en US$
EUR€
a
o
ser debitados de la cuenta abierta con Commonwealth Bank, representa
fondos destinados para:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
BANKING ACTIVITY / ACTIVIDAD BANCARIA
The following questions are regarding your future usage of the account with Commonwealth
Bank / Las siguientes preguntas son sobre el uso futuro que le va a dar a la cuenta en el
Commonwealth Bank:
1. Montlhy volume of credits to be received in the account / Volumen mensual aproximado en
Créditos que recibirá en la cuenta
US$
EUR€
________________________________________
2. Monthly volume of debits to be executed from the account / Volumen mensual aproximado en
debitos que tendrá en la cuenta
US$
EUR€
________________________________________
3. Number of credit transactions to be executed in the account / Numero aproximado de
transacciones mensuales de Crédito en cuenta
Number of Transactions / Numero de Transacciones____________________________
4. Number of debit transactions to be executed from the account / Numero aproximado de
transacciones mensuales de debito en cuenta
Number of Transactions / Numero de Transacciones____________________________
5. Maximum Credit Volume / Volumen de créditos en cuenta en meses de mayor actividad
US$
EUR€
________________________________________
6. Maximum Debit Volume / Volumen de debitos en cuenta en meses de mayor actividad
US$
EUR€
________________________________________
7. Maximum number of credit transactions / Numero de transacciones de Crédito en cuenta en
meses de mayor actividad:
Number of Transactions / Numero de Transacciones____________________________
8. Maximum debit transactions / Numero de transacciones de Debito en cuenta en meses de
mayor actividad:
Number of Transactions / Numero de Transacciones____________________________
Date / Fecha:
Passport #:
Signature / Firma:
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W8 Annex
Individuals
NAME:
YES
NO
Are you a US Person?
If yes, what type of US Person
Do you have more than one nationality?
If yes, please indicate current nationality/nationalities
Name
Date
For Tax purposes US PERSONS include:
• US citizens; Individuals resident in the US based on number of days spent there; US green card holders (even if the green
card has expired); US created corporations; US created partnerships; US estates and trusts; Virtually everyone born in the US
DOCUMENT CHECK LIST - PERSONAL CUSTOMERS
CUSTOMER NAME:
Comply with minimum amount per product / Cumplir con el monto mínimo de apertura
Account Opening Form / Formato de Apertura
Tax ID / Registro de Informacion Fiscal
W8 Ben Format / Formato W8 Ben
Source of Funds Declaration Form / Planilla de Procedencia de Fondos
Financial Activity Form /Planilla de Actividad Financiera
2 Signature Cards / 2 Tarjetas de firmas
An original Bank Reference indicating the average amount managed in the account and years of activity / Una
Referencia Bancaria en original, indicando antigüedad y los promedios manejados en la cuenta
Copy of valid ID and Passport from all authorized signatures /Copia del Documento de Identidad y Pasaporte
vigente y legible para todas las firmas autorizadas
Prove of Residency (Utility Invoice) / Prueba de Residencia (Recibo de Servicio Publico)