Client Ination Sheet 客户信息表—曾总资料.doc

昆山淀山湖庄园房地产发展有限公司 Client Information Sheet 客户信息表In accordance with Articles two (2) through five (5) of the Due Diligence Convention and the Federal Marketing Commission Circular of December 1998, concerning the prevention of money laundering, the following information may be supplied to banks and/or other Federal Institutions for verification purposes.按照反洗钱法，下列提供给银行和/或联邦机构的信息用于查询用。1) Borrowers Name 借方名称：Full Name of Business 公司名称：Business Address 营业地址：Business Registration No. 营业执照号码：Registered Address 注册地址：Telephone 电话号码：Facsimile 传真号码：E-Mail Address 电子邮件号码：2）Signatorys Information 签字人资料Full Name姓名：Nationality国籍：Passport No.护照号码：Passport-Issuing Country护照签发国：Date if Issue护照签发日期：Place of Issue护照签发地：Date of Expiration护照到期日：Date of Birth出生年月日：Place of Birth出生地：SSN/National Identity No.身份证号码：Home Address家庭住址：Home Telephone家庭电话：Mobile Telephone移动电话号码：Facsimile 家庭传真号码:E-Mail Address (personal)个人电子邮件：3）Legal Representative法律顾问Counsel Full Name法律顾问姓名:Law Firm Name律师事务所名称：Address律师事务所地址：Telephone律师事务所电话：Facsimile律师事务所传真：E-mail Address律师事务所电子邮件：4）Borrowers Paying Bank借方付款银行Name of Bank银行名称：Bank Address银行地址：Account Name账户名称：Account/Signatory账户签字人：Account No.账号：Bank Officer银行官员：Telephone银行电话：Facsimile银行传真：E-mail Address银行电子邮件：S.W.I.F.T. Code银行SWIFT代码：ABA Code汇款ABA代码5）Borrowers Receiving Bank借方接证银行Name of Bank银行名称：Bank Address银行地址：Account Name账户名称：Account/Signatory账户签字人：Account No.账号：Bank Officer银行官员：Telephone银行电话：Facsimile银行传真：E-mail Address银行电子邮件：S.W.I.F.T. Code银行SWIFT代码：ABA Code汇款ABA代码6）Funds of Information资金信息Origin资金来源：Are Funds clean and clear?资金是干净、清洁的吗？7）Bank Readiness银行准备My Bank is aware of this YES知道/NO不知道. also transaction enter the name of the bank也要在此写上银行名称我的银行知道此交易Name of Bank Officer银行官员：Contact info email address and telephone 联系信息： number 银行官员电子邮件和电话号码7）Brief Description of Corporate Activities 公司业务活动简述：Declaration 声明：I hereby swear under penalty of perjury, that the information provided is both true and accurate. I am the signatory on the aforementioned bank account. All monies engaged in this transaction are derived from non-criminal origin; and, are good, clean and cleared. The origin of funds is in compliance with Anti-Money-Laundering Policies as set forth by the Financial Action Task Force (FATF) 6/01.我在此宣誓，若作假愿受罚，我所提供信息是真实、准确的。我是前