Corporate Investment Declaration Form

1
CORPORATE INVESTMENT DECLARATION FORM
CORPORATE INFORMATION
D D M M Y Y Y Y
Company Name : __________________________________________ (the “Investor”) Date of new entry/review:
Account No. : Contact No :
Account Type : Branch :
IMPORTANT – PLEASE READ CAREFULLY BEFORE COMPLETING THIS DECLARATION FORM OF RISK APPETITE
The series of questions below help inform Citigroup Global Markets India Pvt. Ltd. (CGM) of the risk appetite of the Private Limited Companies/ Public limited Companies (the
“Investor”) prior to the Investor’s selection of and investment in appropriate investment.
Based on the information you (the authorised representative of the Investor) provide hereunder, CGM will assist the Investor in identifying the products that meet the
Investor’s risk appetite. It is thus very important that accurate and complete information in relation to the Investor is provided, as it will affect the appropriateness of our
product offering(s). You hereby acknowledge and agree for and on behalf of the Investor that if inaccurate and / or incomplete information is provided, and / or certain
information is not disclosed, such action will adversely affect the appropriateness of our product offering(s), for which CGM shall take no responsibility.
The Self-Declaration process of the risk appetite is intended to form a basis for a discussion between the Investor and your CGM Sales Representative on appropriate
investment products for the Investor. The self-declaration does not cover all issues the Investor should consider while investing. Before making any investment decisions, the
Investor should fully understand the product risks and merits, determine that the investment is consistent with the Investor’s objectives and that you on behalf of the Investor
are able to assume the risk.
Please note that this Declaration Form will be “valid” for a period of 12 months starting from the date stated on the Declaration Form and will have to be renewed on an annual
basis.In the event there is a change in the Investor's risk appetite (within the 12 months period), please inform CGM accordingly.
In order to safeguard your interest, it is important that all the documents are duly completed and signed by you, prior to being handed over to CGM/CGM Employee.
ENTITY PROFILE
1. Nature of business of Entity (Please tick the relevant category below)
1 Financial Institution
2 Non-Bank Financial Institution
3 Doctors
4 Trust, Charities, Not-for-profit organizations (receiving or not
receiving donations)
5 Companies having close family shareholdings or beneficial ownership
6 Entity in high risk countries
7 Car/Boat/Plane dealership
8 Gas station
9 Electronics (wholesale)
10 Travel agency
11 Used car sales
12 Jewellery/Gems/Metals
13 Investment Management Company/Mutual funds/Hedge funds
14 Personal Investment Company
15 Money management
16 Telecommunications/Phone Cards/Phone Center
17 Internet business
18 Venture Capital Company
19 Real estate and construction
20 Multi Level Marketing agencies
21 Gaming including internet gaming/Gambling
22 Restaurant/Hotel Business
23 Embassy/Consulate
24 Bar/Casino/Night clubs owners
25 Pawn Shop/Pawn Shop Owners
26 Seller of : Money orders, Traveler’s Cheques , Money transmission, check
Cashing and currency dealing or exchange
27 Lottery business
28 Money service business
29 Import/Export
30 Businesses accepting third party checks (except supermarkets or retail
stores that accept payroll checks/cash payroll checks)
31 Real Estate Brokers
32 Stock Brokerage
33 Art/Antique Dealers
34 Auctioneers
35 Cash-Intensive Businesses such as retail shops, parking garages, movie
theaters, etc.
36 Telemarketers
37 Sole Practitioners - Law Firms (or small, little known)
38 Secretarial Firms (small, little known)
39 Notaries (small, little known)
40 Accountants (small, little known firms)
41 Others (specify)
2. Are you a PEP (Politically Exposed Person) or SPF (Senior Public Figure)? Yes No
3. Whether NOC from the any Exchange OR any Regulatory Authority is required for opening account with CGM? Yes No
4. Does the company have a financial service license? Ye s No . Registration Number
5. Exchange on which the company is a public listed investment company NSE BSE
CWA/CID/Investment/11/13-V4.0
Financial Status
A. Primary Source of Income & Wealth
Operating income Investment income Other income (specify)
B. Estimated Total Net Worth (includes share capital and reserves and surplus)
Below ` 25 Lacs ` 25 Lacs to below ` 50 Lacs ` 50 Lacs to below ` 1 Cr ` 1 Cr to below ` 2 Cr
` 2 Cr to below ` 4 Cr ` 4 Cr to below ` 10 Cr ` 10 Cr to below ` 40 Cr ` 40 Cr to below ` 100 Cr
` 100 Cr and above
C. Estimated Liquid Net Worth (includes the value of all the investible assets, including Cash, Bank Balance, FDs and other Financial Investments)
Below ` 10 Lacs ` 10 Lacs to below ` 25 Lacs ` 25 Lacs to below ` 50 Lacs ` 50 Lacs to below ` 1 Cr
` 1 Cr to below ` 2 Cr ` 2 Cr to below ` 4 Cr ` 4 Cr to below ` 7 Cr ` 7 Cr to below ` 10 Cr
` 10 Cr to below ` 15 Cr ` 15 Cr to below ` 20 Cr ` 20 Cr to below ` 30 Cr ` 30 Cr to below ` 40 Cr
` 40 Cr to below ` 50 Cr ` 50 Cr to below ` 75 Cr ` 75 Cr to below ` 100 Cr ` 100 Cr and above
D. Estimated Total Net Profit
Below ` 1 Lac ` 1 Lac to below ` 5 Lacs ` 5 Lacs to below ` 10 Lacs ` 10 Lacs to below ` 25 Lacs
` 25 Lacs to below ` 50 Lacs ` 50 Lacs to below ` 1 Cr ` 1 Cr to below ` 3 Cr ` 3 Cr to below ` 5 Cr
` 5 Cr and above
Name :
Signature Of Authorized
Signatory With Seal
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