General   Information about your company

Your   company’s legal name:

Operating   name, if different than legal name:

Address   of principal location:

Street:

City:

Country:

Country   of incorporation:

The   nature of your principal activities:

Please   indicate the approximate percentage of your clients by country:

Country:

% of   clients

Country:

% of   clients

Country:

% of   clients

Do your   clients conform to all applicable AML/ATF regulations in their country of   origin?

Yes

No

Does your   company provide “money service business” services (money transmitter/foreign   currency exchange)?

Yes

No

Does your   company accept 3^rd party funds?

Yes

No

Does your   company accept deposits?

Yes

No

Are your   activities regulated by a government agency or department?

Yes

No

If yes,   the name and address of your principal regulator:

Is your   company subject to regulatory and audit inspections?

Yes

No

If yes,   by whom?

Has your   company appointed a senior officer responsibly for its Anti-Money Laundering   and Anti-Terrorist Financing program?

Yes

No

If you   responded “Yes” to the preceding question, please provide the person’s name,   position, title, mailing address, telephone number and e-mail address:

Is the   individual named in the preceding question responsible for Anti-Money   Laundering and Anti-Terrorist Financing activities in all of your   subsidiaries?

Yes

No

If you   responded “No” to the preceding question, please list those entities that the   individual is NOT responsible for:

Name and   Title of individual completing this questionnaire (if other than the   individual named above):

Date the   questionnaire was completed: