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Form for contracting services*

1. Customer Information (To be completed by individuals or company representatives).

• Note: Please provide supporting documentation for all information provided. (Copy of Passport (s), Identification (s), Assembly that grants power of signature, as well as any other document that proves your identity and quality).

2. Customer information (To be completed by companies):

Note: please provide supporting documentation for all the information provided (copy of incorporation documents Tax Id number or R.N.C., Copy of Mercantile Registry. Proof of Ownership by the Final Beneficiaries, copy of the identification document of the final beneficiaries , as well as any other that supports the information contained in this document.

3. Contact information:

4. Source of funds

5.Description of activities carried out by the client:

6. Scope(s) of services required:

• Note: This form must be completed and/or updated by all new and existing clients in accordance with Law No. 155-17, Against Money Laundering and Terrorism Financing, promulgated on June 1, 2017 in the Dominican Republic.

By the Client

Thanks for submitting!

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