Lerolero

Trump Ocean Club Tower, Level 6, Suite 605
Calle Punta Colón, Punta Pacífica, Panamá, Panamá

DUE DILIGENCE DECLARATION
I ________________________________ do hereby provide the information thatappears below on account
of my desire to purchase (product requested) ______________________________.
1.

My lawful name is: ________________________________________________________________

2.Physical residence address is:
_________________________________________________________________________________
Telephone: ___________________________
Fax: _________________________________Email: ________________________________
Postal address is: __________________________________________________________________
Principal place of business is:_________________________________________________________________________________
Telephone: __________________________
Fax: ________________________________
Email: _______________________________

3.

I am citizen of:______________________ and a resident of: _____________________________

4.

True copies of my passport and utility bill not more than three (3) months old i.e.
telephone, water, electricity (a mobil phone andsatellite subscription bill is
unacceptable) are attached to this declaration form.

5.

My business occupation for the past three (3) years has been: _______________________________________________________________________________________________________________

6.

Passport No.: _____________________________________________________________________
Date and Place of Issuance:_________________________________________________________

7.

I further declare that none of my assets, net worth, income or activities relate in any manner to
armaments, illegal drugs or other illegalcontrolled substances, prostitution, money laundering, or

Atlantic Pacific Logisitc, S.A.
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any other activity that I know to be illegal in my country of citizenship, residence or...