KycPartner Client Profile Branch * KhobarJeddahRiyadh Official Company/Supplier Name * Trade Name * VAT Number * SAMA License Number * License Expiry date * CR Details CR Number * CR Expiry Date(Hijri): Day * 010203040506070809101112131415161718192021222324252627282930 Month * 010203040506070809101112 Year * 14401441144214431444144514461447144814491450145114521453145414551456145714581459146014611462146314641465146614671468146914701471147214731474147514761477147814791480148114821483148414851486148714881489149014911492149314941495149614971498149915001501150215031504150515061507150815091510 CR Issue Date(Hijri): Day * 010203040506070809101112131415161718192021222324252627282930 Month * 010203040506070809101112 Year * 14401441144214431444144514461447144814491450145114521453145414551456145714581459146014611462146314641465146614671468146914701471147214731474147514761477147814791480148114821483148414851486148714881489149014911492149314941495149614971498149915001501150215031504150515061507150815091510 Country * AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBrazilBritish Virgin Is.BruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African Rep.ChadChileChinaColombiaComorosCongo, Dem. Rep.Congo, Repub. of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambia, TheGaza StripGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Fed. St.MoldovaMonacoMongoliaMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaN. Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts & NevisSaint LuciaSt Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin IslandsWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabwe Reating (For RI Only) * Client/Provider legal status: * Individual Establishment Company Public listed Company Foreign Company Government Office Charity Other Nature of Business/occupational details * Accommodation and food servicesAdministrative and support, waste management and remediation servicesAgriculture, forestry, fishing and huntingArts, entertainment and recreationConstructionEducational servicesFinance and InsuranceHealth care and social assistanceInformation and cultural industriesManagement of companies and enterprisesManufacturingMining, quarrying, and oil and gas extractionOther services (except public administration)Professional, scientific and technical servicesPublic administrationReal estate and rental and leasingRetail tradeTransportation and warehousingUtilitiesWholesale trade Details of the client Source of Fund * SalaryOthers Is the client from one of Internationally prohibited countries? * Yes No If Yes is select proper Authorization Document should be attached * Drop a file here or click to upload Choose File Maximum file size: 1MB Is any of the shareholder, BoD , or Management classified as PEP*? * Yes No If Yes please provide details of the Name and the reason Drop a file here or click to upload Choose File Maximum file size: 1MB National Adress Information Address * Building No * Unit No * Zip code * Additional No * Contact Information Name of Contact Person * Job Title * CEO (Chief Executive Officer)CFO (Chief Financial Officer)CMO (Chief Marketing Officer)COO (Chief Operating Officer)HR Manager (Human Resources Manager)Sales ManagerMarketing SpecialistFinancial AnalystOperations CoordinatorBusiness Development ManagerBusiness Development AssociateAccountantAdministrative AssistantCustomer Service RepresentativeComplianceLegalInsurance AdminOthers Email address * Country Code * United States of America +1Afghanistan +93Albania +355Algeria +213American Samoa +1-684Andorra +376Angola +244Anguilla +1-264Antarctica +672Antigua +1-268Argentina +54Armenia +374Aruba +297Ascension +247Australia +61Australian External Territories +672Austria +43Azerbaijan +994Bahamas +1-242Bahrain +973Bangladesh +880Barbados +1-246Barbuda +1-268Belarus +375Belgium +32Belize +501Benin +229Bermuda +1-441Bhutan +975Bolivia +591Bosnia & Herzegovina +387Botswana +267Brazil +55British Virgin Islands +1-284Brunei Darussalam +673Bulgaria +359Burkina Faso +226Burundi +257Cambodia +855Cameroon +237Canada +1Cape Verde Islands +238Cayman Islands +1-345Central African Republic +236Chad +235Chatham Island (New Zealand) +64Chile +56China (PRC) +86Christmas Island +61-8Cocos-Keeling Islands +61Colombia +57Comoros +269Congo +242Congo, Dem. Rep. of (former Zaire) +243Cook Islands +682Costa Rica +506Côte d'Ivoire (Ivory Coast) +225Croatia +385Cuba +53Cuba (Guantanamo Bay) +5399Curaçao +599Cyprus +357Czech Republic +420Denmark +45Diego Garcia +246Djibouti +253Dominica +1-767Dominican Republic +1-809 and +1-829East Timor +670Easter Island +56Ecuador +593Egypt +20El Salvador +503Ellipso (Mobile Satellite service) +8812 and +8813EMSAT (Mobile Satellite service) +88213Equatorial Guinea +240Eritrea +291Estonia +372Ethiopia +251Falkland Islands (Malvinas) +500Faroe Islands +298Fiji Islands +679Finland +358France +33French Antilles +596French Guiana +594French Polynesia +689Gabonese Republic +241Gambia +220Georgia +995Germany +49Ghana +233Gibraltar +350Global Mobile Satellite System (GMSS) +881ICO Global +8810 and +8811Ellipso 8812 +8813Iridium 8816 +8817Globalstar 8818 and 8819Globalstar (Mobile Satellite Service) +8818 and +8819Greece +30Greenland +299Grenada +1-473Guadeloupe +590Guam +1-671Guantanamo Bay +5399Guatemala +502Guinea-Bissau +245Guinea +224Guyana +592Haiti +509Honduras +504Hong Kong +852Hungary +36ICO Global (Mobile Satellite Service) +8810 and +8811Iceland +354India +91Indonesia +62Inmarsat (Atlantic Ocean - East) +871Inmarsat (Atlantic Ocean - West) +874Inmarsat (Indian Ocean) +873Inmarsat (Pacific Ocean) +872Inmarsat SNAC +870International Freephone Service +800International Shared Cost Service (ISCS) +808Iran +98Iraq +964Ireland +353Iridium (Mobile Satellite service) +8816 and +8817Israel +972Italy +39Ivory Coast +225Jamaica +1-876Japan +81Jordan +962Kazakhstan +7Kenya +254Kiribati +686Korea (North) +850Korea (South) +82Kuwait +965Kyrgyz Republic +996Laos +856Latvia +371Lebanon +961Lesotho +266Liberia +231Libya +218Liechtenstein +423Lithuania +370Luxembourg +352Macao +853Macedonia (Former Yugoslav Rep of.) +389Madagascar +261Malawi +265Malaysia +60Maldives +960Mali Republic +223Malta +356Marshall Islands +692Martinique +596Mauritania +222Mauritius +230Mayotte Island +269Mexico +52Micronesia (Federal States of) +691Midway Island +1-808Moldova +373Monaco +377Mongolia +976Montenegro +382Montserrat +1-664Morocco +212Mozambique +258Myanmar +95Namibia +264Nauru +674Nepal +977Netherlands +31Netherlands Antilles +599Nevis +1-869New Caledonia +687New Zealand +64Nicaragua +505Niger +227Nigeria +234Niue +683Norfolk Island +672Northern Marianas Islands (Saipan, Rota & Tinian) +1-670Norway +47Oman +968Pakistan +92Palau +680Palestinian Settlements +970Panama +507Papua New Guinea +675Paraguay +595Peru +51Philippines +63Poland +48Portugal +351Puerto Rico +1-787 or +1-939Qatar +974Réunion Island +262Romania +40Russia +7Rwandese Republic +250St. Helena +290St. Kitts/Nevis +1-869St. Lucia +1-758St. Pierre & Miquelon +508St. Vincent & Grenadines +1-784Samoa +685San Marino +378São Tomé and Principe +239Saudi Arabia +966Senegal +221Serbia +381Seychelles Republic +248Sierra Leone +232Singapore +65Slovak Republic +421Slovenia +386Solomon Islands +677Somali Democratic Republic +252South Africa +27Spain +34Sri Lanka +94Sudan +249Suriname +597Swaziland +268Sweden +46Switzerland +41Syria +963Taiwan +886Tajikistan +992Tanzania +255Thailand +66Thuraya (Mobile Satellite service) +88216Timor Leste +670Togolese Republic +228Tokelau +690Tonga Islands +676Trinidad & Tobago +1-868Tunisia +216Turkey +90Turkmenistan +993Turks and Caicos Islands +1-649Tuvalu +688Uganda +256Ukraine +380United Arab Emirates +971United Kingdom +44United States of America +1US Virgin Islands +1-340Universal Personal Telecommunications (UPT) +878Uruguay +598Uzbekistan +998Vanuatu +678Vatican City +39 and +379Venezuela +58Vietnam +84Wake Island +808Wallis and Futuna Islands +681Yemen +967Zambia +260Zanzibar +255Zimbabwe +263 Mobile telephone * Web Page File Upload Drop a file here or click to upload Choose File Maximum file size: 2MB Client Bank Details Bank * Saudi National BankThe Saudi British Bank (SABB)Saudi Investment BankAlinma bankBanque Saudi FransiRiyad BankAl Rajhi BankArab National BankBank AlBiladBank AlJaziraOthers. Branch * AlKhobarJeddahRiyadh Other Bank Name * Swift Code * IBAN Number (Should be 24 Characters) * Volume and frequesncy of transaction * Payment Method * CashTransfer * I/We declare that the above mentioned information and statements are true and correct to the best of knowledge of the undersigned and it has been made in good faith. I further declare and accept that Chubb Company. Will depend on this information in order for them to fulfil as well their regulatory obligations A) Beneficiary Owner and Management Team 1. Please fill in the tables below with details of Shareholders of 25% ownership and above: “As per to SAMA CTF Executive Rules (Article 10/C), the IDs must be provided of shareholderes who own more than 25%” Name Comments Ownership % Nationality AfghanAlbanianAlgerianAmericanAndorranAngolanAnguillanArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBotswananBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseCitizen of Antigua and BarbudaCitizen of Bosnia and HerzegovinaCitizen of Guinea-BissauCitizen of KiribatiCitizen of SeychellesCitizen of the Dominican RepublicCitizen of VanuatuColombianComoranCongolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanDutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianStatelessSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabwean plus4 Add minus4 Remove ID or CR Document Drop a file here or click to upload Choose File Maximum file size: 2MB 2. Please fill in the tables below with details of the Board of directors ( Copies of Id’) Name ID Number Nationality AfghanAlbanianAlgerianAmericanAndorranAngolanAnguillanArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBotswananBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseCitizen of Antigua and BarbudaCitizen of Bosnia and HerzegovinaCitizen of Guinea-BissauCitizen of KiribatiCitizen of SeychellesCitizen of the Dominican RepublicCitizen of VanuatuColombianComoranCongolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanDutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianStatelessSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabwean Job Title: CEO (Chief Executive Officer)CFO (Chief Financial Officer)CMO (Chief Marketing Officer)COO (Chief Operating Officer)HR Manager (Human Resources Manager)Sales ManagerMarketing SpecialistFinancial AnalystOperations CoordinatorBusiness Development ManagerBusiness Development AssociateAccountantAdministrative AssistantCustomer Service RepresentativeComplianceLegalInsurance AdminOthers File Upload Drop a file here or click to upload Choose File Maximum file size: 516MB plus4 Add minus4 Remove 3. Please fill in the tables below with details of the Management Team ( Copies of Id’) Name Job Title: CEO (Chief Executive Officer)CFO (Chief Financial Officer)CMO (Chief Marketing Officer)COO (Chief Operating Officer)HR Manager (Human Resources Manager)Sales ManagerMarketing SpecialistFinancial AnalystOperations CoordinatorBusiness Development ManagerBusiness Development AssociateAccountantAdministrative AssistantCustomer Service RepresentativeComplianceLegalInsurance AdminOthers Nationality AfghanAlbanianAlgerianAmericanAndorranAngolanAnguillanArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBotswananBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseCitizen of Antigua and BarbudaCitizen of Bosnia and HerzegovinaCitizen of Guinea-BissauCitizen of KiribatiCitizen of SeychellesCitizen of the Dominican RepublicCitizen of VanuatuColombianComoranCongolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanDutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianStatelessSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabwean Address File Upload Drop a file here or click to upload Choose File Maximum file size: 2MB plus4 Add minus4 Remove Declaration and Knowledge I hereby declare that the above provided information is true to the best of my knowladge and and on that I sign“ Must be signed by an authrized person , and its ID must be provided” ID Drop a file here or click to upload Choose File Maximum file size: 1MB Name * Signature and Stamp * signature keyboard Clear * PEP : A member of the royal family, ministers, government leaders or political opponents* Kindly note that AML deparment could request more docuemts if it is necessry. 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