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Client Intake Form Revision 1a

This client intake form requires applicants to provide personal and financial information in order to be considered for services. Applicants must complete all sections of the form, including details about the client, their bank information, company information if applicable, the type of service needed and amount, and a description of how any funds or instruments will be used. The form notes that applications will be denied if insufficient details are provided. Applicants must also confirm the accuracy of the information, attach additional required documents like identification and bank statements, and may provide optional bank coordinates for delivery.

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Segaf Sang Pengelana
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345 views5 pages

Client Intake Form Revision 1a

This client intake form requires applicants to provide personal and financial information in order to be considered for services. Applicants must complete all sections of the form, including details about the client, their bank information, company information if applicable, the type of service needed and amount, and a description of how any funds or instruments will be used. The form notes that applications will be denied if insufficient details are provided. Applicants must also confirm the accuracy of the information, attach additional required documents like identification and bank statements, and may provide optional bank coordinates for delivery.

Uploaded by

Segaf Sang Pengelana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Client Intake Form

Applicants must complete ALL sections of the form in order for the application to be processed. This Intake Form
will become part of your contract. Our time is as valuable as yours, so please, only serious applications from
individuals who know what they need and have the funds to pay for the requested service.

CLIENT INFO
Principal Name
Nationality
Drivers' License or Passport
Number
Expiration Date
Date Of Birth
Permanent Address
Primary Phone Number
Secondary Phone Number
Fax Number
E-mail Address

CLIENT BANK INFO


Name of Bank
Branch
Bank Address
Telephone & Fax
Account Number
S.W.I.F.T. Code
Bank Officer #1
Bank Officer #2
Account Name
Account Signatory
Funds Set Aside To Pay
Fees
Are These Funds Liquid,
Free & Clear? YES NO

CLIENT COMPANY INFO


Name of Company
Type of Business Conducted
Business Address
Registered Office
Telephone & Fax Number
Do You Have Any Outstanding
Judgments, Law Suits or Tax
Liens?
Place of Incorporation
Date of Incorporation
Corporation Reg. #/ Employer
ID #
Legal Advisor Name &
Company Name 1 of 4
All information submitted will be handled with strict confidentiality
Client Intake Form
Corporation Reg. #/ Employer
ID #
Principal Structure of Business Corporation Partnership Individual LLC

SERVICE INFO
What Kind of Service Do You POF Blocked Account Instrument
Need?
Amount Needed
Do You Have 15% of This
Amount?
If NO Then How Much Do You
Have?
Type of Instrument [If
Applicable] BG CD Letter of Credit
SBLC
Desired Leasing Term
Desired Closing Date
POF Letter Required [If
Applicable] Proof of Funds Letter Bank Comfort Letter

Capability Letter Blocked Funds Letter

Reserved Funds Letter Tear Sheet


Do You Require A Top 25
World Bank
Desired Bank
Type of Account Confirmation
Required By Phone Letter MT799
MT760

REFERRING AGENT [ IF APPLICABLE ]


The following persons are recognized as our Referring Agent(s):
Referring Agent Name and
PHN #
Referring Agent Email
Referring Agent Name and
PHN #
Referring Agent Email

USE OF ACCOUNT/INSTRUMENT
Provide a detailed description of how you will be using the account/instrument be as detailed as possible. Please do
not simply write funding against instrument, please provide full project details for which you require funding.
Applications will be turned down if the description is only 1 -2 sentences. Provide ALL necessary information
including required text, payment and delivery methods:

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All information submitted will be handled with strict confidentiality
Client Intake Form

ACCURACY OF INFORMATION
I personally represent and warrant, under penalty of perjury, that the information provided is accurate and
complete. Further, I warrant that I have the legal authority to sign on behalf of my self and/or my company. I
agree to notify the leasing provider if the information which has been supplied changes in any manner.

__________________________
Signature
Name of Authorized Signatory
Title
Date

ADDITIONAL DOCUMENTATION REQUIRED

Please attach the following documents when submitting your application:

Companies: Corporate applicants must provide a Certificate of Incorporation and Corporate Resolution, along
with proper identification documents.
Individuals: Individual applicants must supply two documents which show identification (Passport, State ID,
Utility Bill, Etc.)
Authorized Persons: Associated or authorized applicants must provide two forms of identification to prove their
residence and identity.
All Applicants: Applications must be submitted with a bank statement showing the ability to fund the amount
equal to the leasing fee they are able to pay.
Verbiage: Applicants must clearly define the verbiage needed for their transaction if there are special
conditions.
All information requested is in accordance with International Money Laundering Regulations and the US Patriot Act

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All information submitted will be handled with strict confidentiality
Client Intake Form

< IF APPLICABLE >

BANK COORDINATES FOR DELIVERY:

BENEFICIARY
NAME:
fddddddddddd

PASSPORT #:

TELEPHONE +
FAX#:

EMAIL:

BANK NAME:

BANK ADDRESS:

ACCOUNT NAME:

ACCOUNT
NUMBER:

SWIFT CODE:

ABA - ROUTING #:

BANK OFFICER:

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All information submitted will be handled with strict confidentiality
Client Intake Form
BANK OFFICER
PHONE / FAX #:

5 of 4
All information submitted will be handled with strict confidentiality

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