DE OBALDÍA & GARCIA DE PAREDES

DUE DILIGENCE CONFIDENTIAL INFORMATION FOR REGISTERED AGENT AND/OR LEGAL SERVICES

We appreciate the time and effort you take to complete our confidential Due Diligence information duly required by our internal control procedures and the Republic of Panama which establish that we shall maintain general information of last beneficial owners or Shareholders. This information is also necessary to ensure we comply with the Anti-Money Laundering Regulations and the Know your client Polices.

I. GENERAL INFORMATION / INFORMACION GENERAL

NATURAL PERSON – PERSONA NATURAL

Full Name / Nombres y Apellidos Completos:

Date and Place of Birth / Fecha y Lugar de nacimiento:

Nationality and I.D.N. / Nacionalidad y Documento de identidad:

Civil Status / Estado Civil:

Other nationalities / Poseo otras nacionalidades:

Passport / Pasaporte:

Profession/Profesión:

Economic Activity/Actividad Económica:

Total Patrimony – Last Fiscal Period (US$)/Total de Patrimonio – Último Período Fiscal (US$):

Complete Home Address/Dirección Residencial Completa:

Complete Office Address/Dirección Oficina Completa:

Postal Address/Dirección Postal:

Telephones/Telefonos: (1)

(2)

Fax/Facsimil:

Celular:

Twitter:

Facebook:

Instagram:

Email: Correo Electrónico: Personal

Oficina:

Professional Services Intermediary / Intermediario:

Yes/Sí No

Regulated and Supervised Entity / Actividad o Profesional Regulado:

Yes/Sí No

If you are a regulated intermediary, please provide the name, address and website (or phone and email) of the professional bodies or regulatory entities: