IBC APPLICATION FORM 1. a) b) c) NAME OF COMPANY TO BE REGISTERED: (Please provide 3 alternative names in order of your preference) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Note: Company name must end with either words, “Limited”, “Corporation”, “Anonyme”, “Sociedad Anonyme”, “Aktiengesllsschaft” or it’s abbreviation. 2. a) b) c) CAPITAL: Standard Company with authorized share capital up to US 50,000 Company with authorized share capital in excess of US 50,000 Other Please Specify: Yes { } Yes { } No { } No { } 3. PURPOSE OF THE COMPANY & ITS INTENDED BUSINESS ACTIVITIES: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 4. SHAREHOLDER(s): Corporate Nominee Shareholder(s) required: Yes { } No { } If not, please provide necessary information on all Shareholder(s) whether individual or corporate. a) Surname: _____________________________ First Name: __________________________ Nationality: ______________ Passport No: _________________ Occupation ______________ Number of Shares: ________________________ Residential Address:_____________________________________________________________ ______________________________________________________________________________ Tel No.:___________________ Fax No.:__________________ Email: ______________________ ****************************************************************************** b) Surname: _____________________________ First Name: __________________________ Nationality: ______________ Passport No: _________________ Occupation ______________ Number of Shares: ________________________ Residential Address:_____________________________________________________________ ______________________________________________________________________________ Tel No.:___________________ Fax No.:__________________ Email: _____________________ ****************************************************************************** c) Company Name: ________________________________________ Jurisdiction: _______________________________ Registration No: _____________________ Number of Shares: ________________________ Registered Address:_____________________________________________________________ ______________________________________________________________________________ Tel No.:___________________ Fax No.:__________________ Email: _____________________ ****************************************************************************** d) Company Name: ________________________________________ Jurisdiction: _______________________________ Registration No: _____________________ Registered Address:_____________________________________________________________ Number of Shares: ________________________ ______________________________________________________________________________ Tel No.:___________________ Fax No.:__________________ Email: _____________________ *Note: The individual name(s) of the ultimate beneficial owner of a company that is represented as a shareholder is required. 5. DIRECTOR(s): Corporate Nominee Director(s) required: Yes { } No { } If not, please provide necessary information on all Director(s) whether individual or corporate. a) Surname: _____________________________ First Name: __________________________ Nationality: ______________ Passport No: _________________ Occupation ______________ Residential Address:_____________________________________________________________ ______________________________________________________________________________ Tel No.:___________________ Fax No.:__________________ Email: ______________________ ****************************************************************************** b) Surname: _____________________________ First Name: __________________________ Nationality: ______________ Passport No: _________________ Occupation ______________ Residential Address:_____________________________________________________________ ______________________________________________________________________________ Tel No.:___________________ Fax No.:__________________ Email: _____________________ c) Company Name: ________________________________________ Jurisdiction: _______________________________ Registration No: _____________________ Registered Address:_____________________________________________________________ ______________________________________________________________________________ Tel No.:___________________ Fax No.:__________________ Email: _____________________ ****************************************************************************** d) Company Name: ________________________________________ Jurisdiction: _______________________________ Registration No: _____________________ Registered Address:_____________________________________________________________ ______________________________________________________________________________ Tel No.:___________________ Fax No.:__________________ Email: _____________________ 6. IMPORTANT DUE DILIGENCE INFORMATION REQUIRED: I. II. III. IV. Notarized copy of passport and/or drivers license of beneficial owner(s). Recent original letter of references: one from a bank, and the other from an attorney, an accountant that the beneficial owner has dealt with for a minimum of 2 years. Copy of utility bill bearing residential address. Complete copy of the corporate documents where a company is represented as the director/shareholder together with items I, II and III on the ultimate beneficial owner(s). 7. OTHER INFORMATION REQUIRED: I. II. Additional material pertaining to business activities such as pamphlets or brochures. Mailing Address to courier original IBC package: ________________________________ ________________________________________________________________________ ________________________________________________________________________ III. Alternative Email Address____________________________________________ The information referenced above in section 6 are required in keeping with Belize Offshore Formation Ltd. obligations to the IFSC as Registered Agents.