Annex 1

(Art. 21 para. 1)

Form for dealers for compliance with due diligence and reporting duties

Verification of the identity of the customer (Art. 17 AMLO)

Customer:

Surname and first name:

Address:

Date of birth:

Nationality:

Acquisition for a legal entity or partnership?

Yes ◻ No ◻

Company:

Registered office:

Identification of the beneficial owner (Art. 18 AMLO)

◻ The customer is itself the beneficial owner ◻ The customer or its representative hereby declares that the following natural person(s) is/are the beneficial owner(s):

	Person 1	Person 2
Surname / first name
Address
Date of birth
Nationality
	Person 3	Person 4
Surname / first name
Address
Date of birth
Nationality

Signature of the customer or representative:

Additional clarifications (Art. 19 AMLO)

Reporting (Art. 20 AMLO)

Report to MROS: Yes ◻ No ◻

Reasonable grounds for suspicion of:

Place and date:

Signature of the dealer: