ALL FIELDS ARE

MANDATORY

NOTE: Please Use BLOCK LETTERS / CAPITAL

CUSTOMER DATA FORM A
1 IDENTIFICATION INFORMATION
INDIVIDUALS & SELF-EMPLOYED
FULL NAME
DATE OF BIRTH DD/MM/YY

ADDRESS

ID/DP/PASSPORT #
TELEPHONE # HOME CELL

(PASSPORT MANDATORY FOR NON-NATIONALS)

EMAIL
GENDER MALE [ ] FEMALE [ ]

MARITAL STATUS [ ] SINGLE [ ] DIVORCED [ ] SEPARATED

[ ] MARRIED [ ] WIDOWED [ ] OTHER

NATIONALITY

MAKE/MODEL OF CURRENT VEHICLE

PLACE OF BIRTH (COUNTRY)

2 EMPLOYMENT INFORMATION

OCCUPATIONAL INCOME RANGE

OCCUPATION
LESS THAN $5,000 PER MONTH [ ]

EMPLOYER'S NAME $5,000 - $10,000 PER MONTH [ ]

or TRADING AS NAME $10,000 - $15,000 PER MONTH [ ]

$15,000 – 20,000 PER MONTH [ ]

EMPLOYER'S ADDRESS OVER $20,000 PER MONTH [ ]

EMPLOYER'S TELEPHONE #
EMPLOYER'S FAX #

3 FAMILY INFORMATION

OCCUPATIONAL INCOME RANGE

NEXT OF KIN FULL NAME
LESS THAN $5,000 PER MONTH [ ]
RELATION SPOUSE [ ] PARENT [ ] CHILD [ ] OTHER(specify)
$5,000 - $10,000 PER MONTH [ ]

OCCUPATION $10,000 - $15,000 PER MONTH [ ]

$15,000 – 20,000 PER MONTH [ ]

EMPLOYER'S NAME
OVER $20,000 PER MONTH [ ]

EMPLOYER'S ADDRESS

4 TRANSACTION INFORMATION
PAYMENT CURRENCY
VALUE OF TRANSACTION TTD [ ] USD [ ]

OTHER
HOW IS THE TRANSACTION BEING FUNDED?
METHOD OF PAYMENT
LOAN [ ] SAVINGS [ ] OTHER
CASH [ ]

NAME OF FINANCIAL INSTITUTION CHEQUE [ ]

(IF FUNDED BY ANY OTHER PARTY, THEN A CUSTOMER DATA FORM MUST BE FILLED OUT BY THE PERSON FUNDING) LINX [ ]

VISA [ ]
PURPOSE OF THE TRANSACTION
MASTER CARD [ ]

[ ] PERSONAL [ ] BUSINESS [ ] OTHER (specify) WIRE TRANSFER [ ]

OTHER
5 BACKGROUND INFORMATION
POLITICALLY EXPOSED PERSON MEANS:

(a) INDIVIDUALS SUCH AS THE HEAD OF STATE OR GOVERNMENT, SENIOR POLITICIAN, SENIOR GOVERNMENT, JUDICIAL OR MILITARY OFFICIALS, SENIOR EXECUTIVES OF STATE-OWNED
CORPORATIONS AND IMPORTANT POLITICAL PARTY OFFICIALS WHO ARE OR HAVE BEEN ENTRUSTED WITH PROMINENT FUNCTIONS-
(i) BY A FOREIGN COUNTRY; OR
(ii) DOMESTICALLY FOR TRINIDAD AND TOBAGO
(b) PERSONS WHO ARE OR HAVE BEEN ENTRUSTED WITH A PROMINENT FUNCTION BY AN INTERNATIONAL ORGANIZATION WHICH REFERS TO MEMBERS OF SENIOR MANAGEMENT SUCH AS DIRECTORS AND MEMBERS
OF THE BOARD OR EQUIVALENT FUNCTIONS;
(c) AN IMMEDIATE FAMILY MEMBER OF A PERSON REFERRED TO IN PARAGRAPH (A) SUCH AS THE SPOUSE, PARENT, SIBLINGS, CHILDREN AND CHILDREN OF THE SPOUSE OF THAT PARENT; AND
(d) ANY INDIVIDUAL PUBLICLY KNOWN OR ACTUALLY KNOWN TO THE RELEVANT FINANCIAL INSTITUTION TO BE A CLOSE PERSONAL OR PROFESSIONAL ASSOCIATE OF THE PERSONS
REFERRED TO IN PARAGRAPH (A) AND (B)

ARE YOU CURRENTLY OR WERE YOU PREVIOUSLY ANY OF THE FOLLOWING:

A A LOCAL OR FOREIGN HEAD OF STATE/GOVERNMENT OR A SENIOR POLITICIAN? YES [ ] NO [ ]

DETAILS (IF YES)

B A SENIOR EXECUTIVE OF A LOCAL OR FOREIGN STATE-OWNED CORPORATION? YES [ ] NO [ ]

DETAILS (IF YES)

C A SENIOR JUDICIAL OR MILITARY OFFICIAL (LOCAL OR FOREIGN)? YES [ ] NO [ ]

DETAILS (IF YES)

D AN IMPORTANT OFFICIAL OF A FOREIGN OR LOCAL POLITICAL PARTY? YES [ ] NO [ ]

DETAILS (IF YES)
 ALL FIELDS ARE
MANDATORY

5 BACKGROUND INFORMATION (CONTINUED)

ARE YOU CURRENTLY OR WERE YOU PREVIOUSLY ANY OF THE FOLLOWING:

E A DIRECTOR OR BOARD MEMBER OF AN INTERNATIONAL ORGAN ISATION? YES [ ] NO [ ]

DETAILS (IF YES)

F A CLOSE FAMILY MEMBER OR CLOSE PERSONAL OR PROFESSIONAL ASSOCIATE YES [ ] NO [ ]

OF ANY PERSONS WHO CAN FALL INTO CATEGORIES A – E?
DETAILS (IF YES)

6 DECLARATION

BY REASON OF THE REQUIREMENTS OF THE CONSOLIDATED ACTS AND REGULATIONS IN THE ANTI-MONEY LAUNDERING AND COMBATTING THE FINANCING OF
TERRORISM LEGAL FRAMEWORK THAT IS THE PROCEEDS OF CRIME ACT, CHAPTER 11:27, AND THE FINANCIAL OBLIGATIONS REGULATIONS 2014, THE ANTI-
TERRORISM ACT, CHAPTER 12:07, AND THE FINANCIAL OBLIGATIONS (FINANCING OF TERRORISM) REGULATIONS 2011, THE FINANCIAL INTELLIGENCE UNIT OF
TRINIDAD & TOBAGO ACT, CHAPTER 72:01, AND THE FINANCIAL INTELLIGENCE UNIT OF TRINIDAD & TOBAGO REGULATIONS 2011, (COLLECTIVELY REFERRED TO AS
THE "AML/CFT LEGISLATION"), THE COMPLIANCE PROGRAMME OF MASSY MOTORS LTD. REQUIRES THAT IT BE SATISFIED AS TO THE IDENTITY OF ITS CUSTOMER
AND THE SOURCE OF FUNDS BEFORE ACCEPTING DEPOSITS OR FUNDS FOR PURCHASE OF NEW VEHICLES, USED VEHICLES AND/OR LEASING. CONSENT IS HEREBY
GIVEN TO MASSY MOTORS LTD. TO DISCLOSE THIS APPLICATION OR ANY INFORMATION CONTAINED THEREIN OR ANY OTHER RELATED CONFIDENTIAL INFORMATION
OF OUR CURRENT, FUTURE AND OTHER TRANSACTIONS TO LAW ENFORCEMENT AGENCIES, REGULATORY AUTHORITIES, REGULATED PERSONS OR AS OTHERWISE,
WHICH IN THE OPINION OF MASSY MOTORS LTD., IS REQUIRED TO BE DISCLOSED BY LAW. SAVE AND EXCEPT WHERE REQUIRED BY LAW OR IN LEGAL
PROCEEDINGS, MASSY MOTORS LTD WILL KEEP ALL INFORMATION DEEMED CONFIDENTIAL AS PROVIDED BY THE CLIENT IN STRICT CONFIDENCE AND WILL NOT
DISCLOSE TO INDEPENDENT THIRD PARTIES WITHOUT THE CLIENT’S PRIOR WRITTEN CONSENT.

I HEREBY DECLARE AND CONFIRM THAT THE INFORMATION GIVEN BY ME IN THIS APPLICATION IS TRUE AND CORRECT
AND I FURTHER DECLARE THAT I AM NOT ENGAGED IN MONEY LAUNDERING, TERRORIST FINANCING, FRAUD OR OTHER ILLEGAL ACTIVITIES.

I RELEASE AND FOREVER DISCHARGE ALL SUCH PERSONS AND ENTITIES FROM ALL LIABILITIES CONNECTED WITH SUCH DISCLAIMER WHOSOEVER AND
HOWSOEVER ARISING.

CUSTOMER SIGNATURE/ PERSON CONDUCTING TRANSACTION DATE

Note: BELOW is to be signed if the customer is acting on behalf of a third party in a fiduciary capacity (e.g., Attorney-at-law, Notary Public, Trustee, Accountant,
etc.)

I HAVE MADE INQUIRY TO THE BEST OF MY KNOWLEDGE AND BELIEVE THE FUNDS WERE NOT DERIVED FROM OR ARE BEING EMPLOYED IN ANY ILLEGAL
TRANSCTION BY THE PERSON/COMPANY FOR WHOM/WHICH I AM ACTING.

SIGNATURE DATE

7 REQUIRED DOCUMENTS. PLEASE TICK ALL SUPPLIED

ALL INDIVIDUALS

A ONE COPY OF GOVERNMENT IDENTIFICATION (MUST BE A PASSPORT FOR NON-NATIONALS) [ ]

B COPY OF RECENT UTILITY BILL AS EVIDENCE OF PERMANENT ADDRESS [ ]

C LETTER OF EMPLOYMENT (where applicable) [ ]
SELF-EMPLOYED/SOLE TRADER/TRADING AS

A ONE COPY OF GOVERNMENT IDENTIFICATION (must be a passport for non-nationals) [ ]

B COPY OF RECENT UTILITY BILL AS EVIDENCE OF PERMANENT ADDRESS [ ]

C PROOF OF OCCUPATION, SUCH AS, LICENCES, CONTRACTS ETC. (where applicable) [ ]

D CERTIFICATE OF REGISTRATION (if registered) [ ]

E LAST 3 YEARS ACCOUNTS or 3 YEARS PROJECTED ACCOUNTS (if new) OR
OTHER FORM OF PROOF OF SOF (SOURCE OF FUNDS) I.E. BANKER’S REFERENCE LETTER
OR 3 MONTHS BANK STATEMENTS [ ]

OTHER

A PASSPORT & WORK PERMIT - MANDATORY FOR NON-NATIONALS [ ]

B REFERENCE LETTER FROM BANK [ ]

C BANK STATEMENTS [ ]

D ANY OTHER (please specify)

FOR OFFICIAL USE ONLY

UN 2253, OFAC, TT CONSOLIDATED LIST MATCH FOUND: YES [ ] NO [ ] CUSTOMER IDENTIFICATION VERIFIED YES [ ]
NO [ HIGH
R.R. ] [ ] MEDIUM [ ] LOW [ ]

TRANSACTION COMPLETED BY TRANSACTION APPROVED BY:

SALES REPRESENTATIVE SIGNATURE: SALES MANAGER / BRAND MANAGER / LOCATION MANAGER

TRANSACTION CHECKED BY: _ SIGNATURE:

SALES ASSISTANT/COORDINATOR: _ COMPLIANCE REVIEW:

TRANSACTION ACCEPTED [ ] DECINED [ ] SENIOR MANAGEMENT APPROVAL: (WHERE APPLICABLE)

(CHAIRMAN / SVP / AVP)
DATE: _
SIGNATURE:
ALL FIELDS ARE
MANDATORY