Ensayo Clinico Superficial

SEYCHELLES INTERNATIONAL BUSINESS AUTHORITY

Application Form for a Special Licence

This application form is to be filled in conjunction with reading the “Application Guidelines for a Special License Company” and the Companies (Special Licenses) Act, 2003

P.O. Box 991 Seychelles International Trade Zone Roche Caiman Mahé, Seychelles Telephone: Fax: Email: Website: +248 280 800 +248 380888 siba@seychelles.net www.siba.net

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INSTRUCTIONS FOR APPLICATION FORM
A. Instructions for Completing the Application Form Answers to ALL questions should be written in INK in BLOCK LETTERS or TYPED. If there is insufficient space on the printed forming which to answer a question, additional information may be provided on an attachment page, a form that is attached. Pleaseidentify the continuation of an answer by stating the question number. All dates should be completed in the form: Day / Month / Year Where the Applicant believes that a question does not apply, the Applicant should write “Not Applicable” or “N/A”. No question should be left unanswered. This form is to be completed in English. Any documents required are to have a certified English translation appended.All amounts are to be recorded in United States Dollars (US$). Conversion from foreign currency should be made using the current exchange rate. Please ensure that all answers and information are true and correct. Failure to do so constitutes a criminal offence and can lead the Authority to reject an application or revoke a license that has been granted on the basis of untrue or incorrectinformation. Please attach to this form one (1) certified copy of passport for the secretary, directors and beneficial owners. Categories of Acceptable Certifiers i. A notary public ii. A barrister or solicitor to the Supreme Court iii. A judge

NOTE: Failure to disclose and submit all necessary information may lead to the Authority rejecting the application.

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APPLICATION FORM
1.PROPOSED NAME OF COMPANY

2.

APPLICANT’S DETAILS

Name of Company’s Secretary

Registered Address in Seychelles

Telephone Fax Email National Identity Number or Passport Number or Company Incorporation Number. 2.1 If the Company exists already, please indicate 2.1.1 2.1.2 2.1.3 Country of Incorporation / Registration _______________________________________ Date of Incorporation /Registration: _________________________________________ Mode of Incorporation / Registration (please tick below) Continuation Change in legal structure from IBC to CSL

3.

PROPOSED ACTIVITY
Please list proposed activity by ticking the appropriate box:
Investment Management and Advice Offshore Banking Offshore Insurance Reinsurance An Investment Company A holding Company A marketing Company A Companyholding intellectual property A headquarters company A human resource company A franchise company A business under the ITZ Other activity which will be subject to approval by the Authority (please specify in opposite area)

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APPLICATION FORM (cont…)
4. CORPORATE DETAILS
4.1 Contact Details of Directors Resident Director 1 Name: Director also known as: Residential Address:Telephone Fax Email Resident Director 2 Name: Director also known as Residential Address:

Telephone Fax Email Non-Resident Director 1 Name Name also known as Residential Address

Telephone Fax Email Non-Resident Director 2 Name: Name also known as Residential Address:

Telephone Fax Email NOTE: Please provide the following documents for each director: Certified true copy of passport Certifiedproof of residential address Copy of CV Page 4 of 8

APPLICATION FORM (cont…)
4.2 Contact Details of Company’s Auditors Name Address

Telephone: Fax: Email: 4.3 Contact Details of Company’s Legal Advisor Name Address

Telephone Fax: Email:

5.

BENEFICIAL OWNERSHIP

(Please use a separate sheet the space below is insufficient) A. Contact Details of Beneficial Owners Name Address...