I CERTIFY that the above information is complete and correct to the best of my knowledge and belief and I
undertake that, as long as I continue to be a director, shareholder, manager, officer or controller of an
institution authorized under the Anjouan Offshore Finance Authority laws, I will notify the Anjouan Offshore
Finance Authority of any material changes affecting the completeness of the answers to questions 1 - 15
above within a period of twenty-one days.
I also hereby authorize the Anjouan Offshore Finance Authority and their agents to make such enquiries and
seek such further information as it thinks appropriate in verifying the information given in this Personal
Questionnaire, or in any other documents submitted as part of this application, for the purposes of
performing its due diligence and background checks. I understand that the results of these checks may be
disclosed to the person who submitted this application.
(FOR ADDITIONAL BENEFICIAL OWNERS PLEASE COPY AND COMPLETE THE ABOVE TABLE)
(FOR ADDITIONAL SHAREHOLDERS PLEASE COPY AND COMPLETE THE ABOVE TABLE)
Only one shareholder is required to set up a company
Initial Due Diligence
Please email copies of the following documents with the originals by post.
I/We certify and confirm, to the best of my/our knowledge and belief, that the above information (including
annexure) is complete, and that the above Beneficial Owners have taken the appropriate legal, tax, exchange
control and relevant professional advice in the particular circumstances. I/We further certify and confirm,
to the best of my/our knowledge and belief, that none of the above Beneficial Owners, directors or officers
of the Company has ever been convicted in a Court of Law for a criminal offence, penalized, sanctioned, is
currently or has ever been under investigation for professional negligence or malpractice by any regulatory
authority in any country. I/We also undertake that no transactions or documents will be entered into until
notified in writing to Anjouan Corporate Services Ltd that all relevant consents have been obtained and that
the proposed company may commence trading. I/We further undertake to enter into the standard company
management agreement in respect of Anjouan Corporate Services Ltd management of the Company. I/We,
acknowledge having taken full cognizance and understood the fees and accept them. I/We confirm we have no
objection in Anjouan Corporate Services Ltd either directly of via a third party using any credit reference
agency
To be signed by the Beneficial Owner or his professional Intermediary and Witness
To
The Managing Director
Anjouan Corporate Services Ltd
Place Pangahari , Mutsamudu
Anjouan
Union of Comoros
I/We declare and warrant that the moneys and/or assets so introduced:
1. do not emanate from any activity, which is illegal or unlawful, or from any activities specified in the
Anti-Money
Laundering Act.
2. are free from any legal encumbrance or restraint imposed by any Court or third party and I/We affirm that
there is no
pending or threatened claims against me/us with regard to the moneys and assets introduced in the proposed
company.
I/We confirm that if the Anjouan Corporate Services Ltd is required by any lawful governmental authority to
determine
the source of funds, I will provide Anjouan Corporate Services Ltd or their agents with the necessary
information and
explanations to establish that the source of funds is from a lawful activity.
CONDITIONS OF APPLICATION
I/we understand that I/we have received legal and tax advice from my/our independent advisors with regards to my/our intended use of the entity and that in requesting the provision of the entity and the services I am not relying on any legal or tax advice from Anjouan Corporate Services Ltd and I confirm that such advice has neither been offered nor received from Anjouan Corporate Services Ltd or its employees or agents.
I/we state, under penalty of perjury, that the company will not be used for any activity which is an offence or predicate offence of money laundering (which term shall be given the widest meaning attributed to it under the law and by international convention), including but not limited to receiving, investing, converting or distributing the
proceeds from drug trafficking, terrorist activities; extortion; or criminal activities generally, or trading with such
countries as might from time to time be subject to any embargo imposed by the Security Council of the United Nations, the
United States or the European Union, or child pornography, prostitution, terrorist activities, receiving proceeds of
drug trafficking, trading in arms, munitions or other weapons or for any purpose which is illegal under the law of
the place of incorporation or management.
I/we swear and attest, under penalty of perjury, that I/we have completed this form, and that the information contained herein is true, accurate and complete, to the best of my/our knowledge. I understand that Anjouan Corporate Services Ltd and its affiliated companies, directors, agents, servants and/or employees are relying upon the accuracy of the information contained in this application. I further understand that Anjouan Corporate Services Ltd may terminate its relationship with me if it is determined any time that any of the information contained herein is false and that
it was provided with the knowledge that it was false, and no refunds will be made.
I understand that if it is determined that any of the information, I provide to Anjouan Corporate Services Ltd, and its affiliated companies, directors, agents, servants and/or employees was provided with the knowledge that it was false, I may be subject to criminal prosecution and if the License is revoked, no refund will be made.
I/we, the person (s) whose names is/are the one that appears on the bottom, by means of this document I/we
declare and
with my own signature confirm:
I/we will at all times irrevocably and unconditionally hold harmless and indemnify Anjouan Corporate Services Ltd and any parent, subsidiary or affiliate thereof and their directors, partners, officers and employees against all proceedings, suits, damages, fines, expenses, penalties and liabilities arising or brought against any of them by reason of any breach of the above declarations or the provision of the Company and/or the Services to me or my use thereof;
