KYC Form C7 | Cosbots

kyc

INFORMATION

KYC Form

kyc

INFORMATION

KYC Form

Please complete the online KYC form and we will get back to you!

Date Form Submitted: *

Know Your Customer “KYC”

Kindly Submit with Certified ID/ Omang Copy

Please select your Membership / Beneficiary *

Group Member
Individual Member
Beneficiary

Applicant/User’s Details

Title, Name and Surname *

Trading Name / Stage Name: *

Nationality *

Date of Birth *

Omang / Passport *

Deceased Name *

Group Name *

Address and Contact Details

Postal Address *

Address: *

Address Line 1

City

State / Province / Region

Telephone *

Mobile *

Employer *

Email:

Occupation *

Place of Work *

Banking Details

Bank Name *

Branch *

Account Number *

Account Type *

Source of Funds *

Beneficiary Details (if changed)

Full Names & Surname *

Mobile *

Relationship *

Declaration

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be liable for it.

Full Names & Surname *

Date *

Place *

Signature Clause: *

Please Tick:

By signing below, you agree that: (i)You have read, understood, and accept the above recorded terms (ii) All information you have provided is correct and complete (iii) You have authority to sign on behalf of the licensee