To be completed by the agent/intermediary. Please complete, sign and return to [insert name]. 1 General Required information Response Company or individual name [Insert company/individual name] Address [Insert address] Principal country of business [Insert country] Other countries of business [Insert country] Individual or corporate entity? ☐ Individual—please go to section 3☐ Corporate entity Primary Contact(name, title and contact details) [Insert primary contact] 2 Ownership and management For corporate entities only. 2.1 Owners of interests greater than [5%] Name Percentage ownership (%) [Insert name] [Insert percentage] [Insert name] [Insert percentage] [Insert name] [Insert percentage] [Insert name] [Insert percentage] 2.2 Directors/officers/partners Name Title [Insert name] [Insert title] [Insert name] [Insert title] [Insert name] [Insert title] [Insert name] [Insert title] 2.3 During the last [insert, eg five years] have any of your owners, directors, partners etc been government employees or officials, officials of a political party, candidates for public office or officials of a public international organisation (collectively ‘government officials’)? ☐ Yes—attach a separate sheet identifying names, dates, titles and details ☐ No 2.4 To your knowledge, during the last [insert, eg five years] have any of your owners, directors, partners etc been closely connected (ie having family, personal or business ties) to a government official? ☐ Yes—provide details on a separate sheet ☐ No 2.5 To your knowledge, during the last [insert, eg five years] have any of your