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Company Registered Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is the correspondence address the same if the registered address?*
Correspondence Address(if different from above)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Authorized Sinatories*
Residential Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
ID/ Passport NO. / Company Reg. No.*

Name of Authorized Sinatories*
Residential Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
ID/ Passport NO. / Company Reg. No.*
Date of Birth*
MM slash DD slash YYYY
Director ( Yes / No )*
Shareholding (% of holding)*

Name of Authorized Sinatories*
Residential Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
ID/ Passport NO. / Company Reg. No.*
Date of Birth*
MM slash DD slash YYYY

Name*
First Name Last Name
Phone*
Date of Birth*
MM slash DD slash YYYY
Nationality*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment Information*
Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Self-Employment Information*
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sources of Income*
Expected Trading Size*
Bank Account
Referred by
Will there be any authorized person(s) or any controlling person(s) identified for this account? (If yes, please provide the details of the authorized persons in the following boxes)
- Yes
- No

Declaration*
We hereby declare that the above information provided by us is true, complete and correct and that we have not wilfully withheld any material fact. We further declare that we have never been made bankrupt and there is no litigation or petition filed against us in the past or presently. In addition, we declare that we have never committed any offence under any laws. We hereby authorize and give QCP Capital Pte Ltd (“QCP”) our irrevocable consent to make such enquiries and conduct all the necessary checks on us and obtain from and/or verify with any source and/or disclose or release any information relating to us to any party or source as QCP, may from time to time, deem fit without any liabilities or notice to us. We hereby authorize QCP to disclose any information of us and/or data relating to ourselves to the Vendor (seller), Supplier and/or Dealer by phone, electronic mail, short messaging service (SMS) or any means of communication which QCP deems appropriate. We hereby further acknowledge that QCP reserves the right to reject our application without assigning any reason and retain documents submitted by us.
- I have read and agree to the terms in the Declaration.

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