Nasabah Baru Institusi Pembukaan Rekening Investor Niaga Cust Info
Statement of Individual Ultimate Beneficial Owner(s)
To: PT Bank CIMB Niaga Tbk.
Company Name
Address
I, _______________________________ (Full Name), as a _____________________ (Occupation) of the above
mentioned company, hereby declare that at the time this document was signed, the following names are individuals who
have a share in the company for at least 25% or more, either directly, or indirectly.
Full Name of
Individual Beneficial Owner(s)
Alias (If any)
Full Address
Nationality
Birth Place & Date of
Birth
Percentage
Interest (%)
NB: Extra lines for name should be added
I, on behalf of the company stated that will immediately inform the PT Bank CIMB Niaga Tbk if there is a change in
ownership information related to the data mentioned above.
Signature:
Full Name:
Occupation:
Date:
(To be completed by an officer authorized to represent the company)
To: PT Bank CIMB Niaga Tbk.
Company Name
Address
I, _______________________________ (Full Name), as a _____________________ (Occupation) of the above
mentioned company, hereby declare that at the time this document was signed, the following names are individuals who
have a share in the company for at least 25% or more, either directly, or indirectly.
Full Name of
Individual Beneficial Owner(s)
Alias (If any)
Full Address
Nationality
Birth Place & Date of
Birth
Percentage
Interest (%)
NB: Extra lines for name should be added
I, on behalf of the company stated that will immediately inform the PT Bank CIMB Niaga Tbk if there is a change in
ownership information related to the data mentioned above.
Signature:
Full Name:
Occupation:
Date:
(To be completed by an officer authorized to represent the company)