BANKING RELATIONSHIP APPLICATION FORM

Transcription

1 BANKING RELATIONSHIP APPLICATION FORM You can open 3 free accounts : a current account, a savings account and a trading account with maximum 3 accountholders : in this case, please use a copy of this document. You would like to hold one of the following with Keytrade Bank SA/NV, Bld du Souverain/Vorstlaan 100, B-1170 Brussels: Accountholder 1 bank card (Bancontact / Mister Cash - Maestro, free of charge) Accountholder 2 bank card (Bancontact / Mister Cash - Maestro, free of charge) To be issued a bank card, you must be a Belgian resident. Debit cards are issued only when one of your accounts presents a credit balance of at least 50. The PIN and the card are sent to your postal address. If you choose a bank card, by signing this document, you declare that you have read, understood and accepted the Specific Conditions debit cards, which can be found at the Document Centre at To apply for a Visa or American Express card, complete online the application form which you can find at We do t open accounts for «US persons». 1. PERSONAL DATA (all details are compulsory) ACCOUNT HOLDER 1 Language French Dutch Mr Mrs English ACCOUNT HOLDER 2 French Dutch Mr Mrs English Surname First name(s) Gender Civil status Official domicile1 Postal address if different from official domicile Country of tax residence if different from official domicile Mobile number Telephone number address Date of birth Place and Country of birth Nationality Other Nationalities Identity card number Valid until National Register identification number or Tax identification number2 Purpose of bank account (2) Personal Business* VAT/company number:... Commercial name:... If you are t a Belgian resident, you also need to complete the "Withholding Tax Certificate" document, which you can find at For Belgian residents it s the National Register number. For n-belgian residents, please visit the website of the European Commission: * Warning, the account cant be used as third-party account. 0001/E11/09/2015 (1) Personal Business* VAT/company number:... Commercial name:...

2 ACCOUNT HOLDER 1 Occupation / Business Code for (**):... Code for (**):... Inside information If : Politically engaged person3 ACCOUNT HOLDER 2 If : If : If : Are you likely to obtain inside information on financial markets? Are you likely to obtain inside information on financial markets? If, wich securities (Issuer and ISIN code)?:... If, wich securities (Issuer and ISIN code)?:... (3) A person who holds or has held a political mandate or a public position on a regional, national or international level as head of state, minister, Member of Parliament, leader of a political party represented in government, senior civil servant (the executive, including the army, and the judiciary), manager of a national public body, senior politician or senior official of an international or upranational organisation, such as the EU, NATO or the UN. (*) Make your choice from the attached list with different sectors; write down the corresponding code. (**) Make your choice from the attached list with liberal professions; write down the corresponding code

3 2. PROXY HOLDER PROXY HOLDER 1 Mr. Mrs. PROXY HOLDER 2 Mr. Mrs. Surname First name Gender Civil status Official domicile Postal address if different from official domicile Code for (**):... Code for (**):... Mobile number Telephone number address Date of birth Place and Country of birth Nationality Other Nationalities Identity card number Valid until National Register number Occupation / Business (*) Make your choice from the attached list with different sectors; write down the corresponding code. (**) Make your choice from the attached list with liberal professions; write down the corresponding code

4 PROXY HOLDER 1 PROXY HOLDER 2 Politically engaged person4 Inside information If : If : If : If : Are you likely to kw insider information about the financial markets? Are you likely to kw insider information about the financial markets? if, which securities (Issuer and ISIN code)?:... if, which securities (Issuer and ISIN code)?: DECLARATION I declare and ackwledge that: - I am t a «US person». The term US person must be interpreted in accordance with the American law in force and I declare that I am fully responsible for ascertaining whether I am categorised or t as a US person. If in any doubt, I must contact a specialised tax adviser. If I was to be categorised as a US person during the service offer, I must immediately tify Keytrade Bank. If I do t tify the Bank in time, I will be responsible for any prejudice caused by this. As a result of American regulation and legislation, Keytrade Bank does t provide any services to US persons and therefore will accordingly be authorised to bring an end to its customer relationship. Information communicated to Keytrade Bank: - The information provided when the bank account is opened, in this document and appendices, is accurate, up-to-date and complete. - The credit balances on the account are t and shall t be of illegal origin, r are they and r shall they be used for the purposes of money laundering or the financing of terrorism. - The accountholder(s) is (are) the effective beneficiary of the credit amounts which shall be deposited in the accounts and I undertake to tify Keytrade Bank immediately if this is t or were longer to be the case, and to send it all useful information with a view to identification of the effective beneficiary (beneficiaries). Remote contract: - I have been advised that, in the case of conclusion of a remote contract for opening an account, the accountholder(s) have a period of 14 calendar days following the opening of the account in which to waive the contract. By using Keytrade Bank products or services during the period, I am expressing my consent to execution of the contract before expiry of the waiver period. Methods of communication: - I have chosen to receive by , via the transactional site, via the website or, as Keytrade Bank may choose, by any other appropriate means of remote communication, any information which Keytrade Bank is statutorily required to send me or considers appropriate to send me in the context of our relationship5. Orders on financial instruments: - I accept responsibility for all risks relating to orders on financial instruments submitted for and on my behalf to Keytrade Bank, on the understanding that Keytrade Bank may t be held liable for the suitability of my investment decisions or the financial outcome of the orders. Protection of personal data: - The personal information collected by Keytrade Bank when the account is opened or during the banking relationship shall be processed by Keytrade Bank, the party responsible for the processing of these data, in accordance with the regulation on the protection of privacy. They shall mainly be processed for the purposes of managing the bank account, control, preparation of market analyses, statistics, internal tests and studies. They may also be processed for canvassing and direct marketing relating to products promoted by the Bank, by companies belonging to the group of which the Bank forms part or, where appropriate, by third parties, but in the latter case, without communication of these data to these third parties (barring objection when the account is opened). More detailed information about the collection, registration, processing and, where applicable, communication of these data to third parties and about the right of consultation, correction and objection is contained in the section entitled "Private life" in the General Terms and Conditions of Keytrade Bank. - My telephone conversations with Keytrade Bank may be recorded by Keytrade Bank, in accordance with the section entitled "Proof" of the General Terms and Conditions, for evidentiary purposes (in particular, but without being limited to, with regard to me or the supervisory and/or legal authorities), and that these recordings are kept for a period necessary for achievement of the aims sought. - Article 322, 3 of the 1992 Income Tax Code, and the Royal Decree of 17 July 2013 require Keytrade Bank to communicate, once a year, data concerning its customers and their contracts to the Central Point of Contact held by the National Bank of Belgium (NBB), Boulevard de Berlaimont/Berlaimontlaan 14, B-1000 Brussels (hereinafter the "CPC"). Detailed information about the data sent to the CPC, about the use that may be made of the data and about the rights of the undersigned on this subject is available on our website Contractual documents: - I have read the following documents available at any time at or on the transactional site, have understood them and accept them unconditionally: * the General Terms and Conditions, the Fees and Conditions, Interest, Exchange Rates for Payment Transactions and Offer of Payment Products and Services, * the terms and conditions of use of the website * the key information for savers regarding the Azur Savings Account and the key information for savers regarding the High Fidelity Savings Account,, along with the complete regulations of Keytrade Bank concerning these accounts. These documents are ed to you when the account is opened and are also available, on request and free of charge, from Keytrade Bank. Changes: - I undertake to immediately tify the Bank of any change in the information provided, particularly any change in (n-) resident status for tax purposes. (4) A person who holds or has held a political mandate or a public position on a regional, national or international level as head of state, minister, Member of Parliament, leader of a political party represented in government, senior civil servant (the executive, including the army, and the judiciary), manager of a national public body, senior politician or senior official of an international or supranational organisation, such as the EU, NATO or the UN. (5) I ackwledge that I have been advised that in some cases, the applicable regulation allows me the option of receiving certain information in hard copy format or in ather format. With regard to its internet bank status, Keytrade Bank's policy is to favour means of communication other than paper, and to only enter into a contractual relationship with customers accepting these methods of communication. By applying to open an account with Keytrade Bank, I accept this policy.

5 Where did you hear about Keytrade Bank? Press advertising radio television internet Trade fairs Word of mouth mailshot You agree to your personal data being used by Keytrade Bank for commercial purposes and also authorize Keytrade Bank to send you by commercial communications for the products and services promoted by Keytrade Bank In the case of the above acceptance, at all times you have the right to object to the use of your personal data for direct marketing purposes and/or the use of your address for sending advertising communications, by sending an to or a letter to the Legal Department at Keytrade Bank's address. 4. REQUISITE ENCLOSURES The requisite enclosures with this document, duly completed and signed, are as follows: - A copy of both sides of the identity cards of accountholders AND proxy holder The copy (both sides, in black and white, A4 format) must be legible and the photo must be clear and recognisable. The date of validity of the identity document must t have expired. - Recent proof of address (maximum 3 months) of accountholders AND proxy holder for t Begium resident By way of example, the following are accepted as proof of address: the original of a health insurance company label, a copy of a tax tice of assessment or a copy of a gas, water, electricity or telephone bill dated within the last 3 months at the most. - The certificate of withholding tax for n-residents (if applicable) Have you answered all questions and included all the requisite enclosures? Your application will only be processed quickly if it is complete. All information shall be treated confidentially. Place and date:... SIGNATURE ACCOUNTHOLDER 1 SIGNATURE ACCOUNTHOLDER 2 By signing this form, the authorised representative confirms their acceptance of the Bank's General Terms and Conditions, and in particular of Article relating to power of attorney. SIGNATURE PROXY HOLDER 1 If you have a promo code, enter it here: Keytrade Bank nv - sa Vorstlaan 100 Bld du Souverain B-1170 Brussels, Belgium. T F info@keytradebank.be- keytradebank.be BTW-TVA BE RPR - RPM Brussels - FSMA SIGNATURE PROXY HOLDER 2

6 List with sectors of activity & Liberale profession Codes for sector of activity: 1 Agriculture, forestry and fishing 2 Mining and quarrying 3 Manufacturing 4 Electricity, gas, steam and air conditioning supply 5 Water supply; sewerage, waste management and remediation activities 6 Construction 7 Wholesale and retail trade; repair of motor vehicles and motorcycles 8 Transportation and storage 9 Accomodation and food service activities 10 Information and communication 11 Financial and insurance activities 12 Real estate activities 13 Professional, scientific and technical activities 14 Administrative and support service activities 15 Public administration and defence; compulsory social security 16 Education 17 Human health and social work activities 18 Arts, entertainment and recreation 19 Other service activities 20 Activities of households as empoyers; Undifferentiated goods- and services-producing activities of households for own use 21 Activites of extraterritorial organisations and bodies Codes for s: Dispensing chemist in specialised stores Activities of bank agents and brokers Risk and damage evaluation Intermediation in buying, selling and rental of real estate Intermediation in buying, selling and rental of real estate Appraisal services in connection to buying, selling and rental of real estate Activities of lawyers Activities of taries Activities of bailiffs Activities of accounting and tax consultancy Activities of bookkeeping and tax bookkeeping Activities of auditing Activities of building architect Activities of interior decorating Town and city planning and landscape architecture Surveying activities Translation and interpretation activities Veterinary activities General medical practice activities Specialist medical practice activities Dental practice activities Activities related to mental health, except psychiatric hospitals and homes Activities of physiotherapists Activities of nurses Activities of midwives Other human health activities