IPOCAMPUS

International Business Agency

Application Form

Print, sign and attach to email:
 
IPOCAMPUS HOLDING                     -                     APPLICATION FORM
 
*  =  VOICES OBLIGATORY
CUSTOMER INFORMATION
Company name*
Type of legal entity
Date of incorporation*   (write in pen)
Registration number*
Taxpayer registration number*
Phone*
City/State:
Registered office*
Country*
Zip code*
E-mail*
Web site*
Preferred means of communication  E-mail  Phone
Brief Description of Primary Company Activity*
 
BUSINESS PROFILE
 Agriculture, forestry and fishery  Extraction industry, quarry operations
 Processing industry  Electricity, gas supply, heat supply, air conditioning
 Services and consultancy (Please describe)  Construction
 Wholesale and retail; automotive and motorcycle repair  Transportation and storage
 Lodging and catering services  Information and communications services
 Financial and insurance activities (with license only)  Real estate transactions
 Professional, scientific and technical services  Administration and services
 State governance and defense; mandatory social insurance (Subject to compliance dept approval)  Education
 Health and social care  Art, entertainment and leisure
 
FULL DESCRIPTION OF BUSINESS ACTIVITIES
Full description of the business, activities and operations
 
I confirm that the aforementioned business activities do not require a licence or special permit at the place of business.
The aforementioned business activities require a licence or special permit at the place of business and I attach a copy of the licence and/or special permit.
 
BUSINESS ACTIVITIES
Duration of business activities (years)
 Up to 1  1-3  3-5  5-7  More than 7
 
Number of employees of the company:
 Up to 10  10 - 50  50 - 250  More than 250
 
Key financial indicators. Annual sales volume of the company (USD /EUR. Please circle appropriate currency):
 Up to 2  2 - 10  10 - 50  More than 50
 
Total assets on the company’s balance sheet (USD /EUR mio. Please circle appropriate currency):
 Up to 2  2 - 10  10 - 43  More than 43
 
 
AUTHORISED SIGNATORY DETAILS
First name*
Last name*
Passport/ID no*
Nationality
Telephone no*
Fax no*
Designated email address*
Address*
City/State*
Zip code*
Country*
 
DIRECTORS OF THE COMPANY
 
First name*
Last name*
Passport/ID no*
Nationality
Telephone no*
E-mail*
Address*
 
ULTIMATE BENEFICIARY DETAILS
 
Share(%)*
First name*
Last name*
Passport/ID no*
Nationality
Telephone no*
E-mail*
Address*
 
SOURCE OF INITIAL FUNDING
 
Value of Initial Funding*
Currency of Initial Funding*
Originating Bank Name*
Originating Bank Address*
Account Name*
Account Number*
Signatory*
Describe precisely how these funds were generated*
DETAILS ABOUT YOUR PRIMARY CURRENT ACCOUNT:
Account currency*
INTERMEDIARY:
Recommended by*
 
REASON FOR CHOOSING IPOCAMPUS HOLDING:
 Beneficial conditions of cooperation  Recommendations from partners/acquaintances  Individual approach to the Customer
 Other (Please specify)
SOURCE OF INFORMATION ABOUT IPOCAMPUS HOLDING:
 Ipocampus Holding - Hoborn Corporation employee  Regional office employee  Agent  Business partner
 TV, radio, press  Conference, seminar
 Other (Please specify)
             

               

  Date    

      

                                  Signature 

 

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