General Information about your company

Your company’s legal name:

Operating name, if different than legal name:

Address of principal location:

Street:

City:

Country:

Country of incorporation:

The nature of your principal activities:

Please indicate the approximate percentage of your clients by country:

Country:

% of clients

Country:

% of clients

Country:

% of clients

Do your clients conform to all applicable AML/ATF regulations in their country of origin?

Yes

No

Does your company provide “money service business” services (money transmitter/foreign currency exchange)?

Yes

No

Does your company accept 3^rdparty funds?

Yes

No

Does your company accept deposits?

Yes

No

Are your activities regulated by a government agency or department?

Yes

No

If yes, the name and address of your principal regulator:

Is your company subject to regulatory and audit inspections?

Yes

No

If yes, by whom?

Has your company appointed a senior officer responsibly for its Anti-Money Laundering and Anti-Terrorist Financing program?

Yes

No

If you responded “Yes” to the preceding question, please provide the person’s name, position, title, mailing address, telephone number and e-mail address:

Is the individual named in the preceding question responsible for Anti-Money Laundering and Anti-Terrorist Financing activities in all of your subsidiaries?

Yes

No

If you responded “No” to the preceding question, please list those entities that the individual is NOT responsible for:

Name and Title of individual completing this questionnaire (if other than the individual named above):

Date the questionnaire was completed: