KYC form ﻤﻧﻮذج اﻋﺮف ﻋﻤﻴﻠﻚ
General Information ﻣﻌﻠﻮﻣﺎت ﻋﺎﻣﺔ
Official Company's Name اﺳﻢ اﻟﴩﻛﺔ اﻟﺮﺳﻤﻲ
Trading Name اﻻﺳﻢ اﻟﺘﺠﺎري
Ultimate اﳌﺴﺘﻔﻴﺪ
Beneficiary اﻟﺤﻘﻴﻘﻲ
Commercial Registration No. رﻗﻢ اﻟﺴﺠﻞ اﻟﺘﺠﺎري
Expiry ﺗﺎرﻳﺦ اﻹﻧﺘﻬﺎء
Legal Structure اﻟﻜﻴﺎن اﻟﻘﺎﻧﻮﻲﻧ
Industry Type اﻟﻨﺸﺎط
Business Activity اﻻﻧﺸﻄﺔ اﻟﺘﺠﺎرﻳﺔ )ﺣﺴﺐ
)(As per CR اﻟﺴﺠﻞ اﻟﺘﺠﺎري(
VAT Number رﻗﻢ ﴐﻳﺒﺔ اﻟﻘﻴﻤﺔ اﳌﻀﺎﻓﺔ
)(VAT Certificate is required )ﺷﻬﺎدة ﺗﺴﺠﻴﻞ ﰲ ﴐﻳﺒﺔ اﻟﻘﻴﻤﺔ اﳌﻀﺎﻓﺔ ﻣﻄﻠﻮﺑﺔ(
)Annual Turnover Approximate (In millions اﻟﺪﺧﻞ اﻟﺴﻨﻮي اﻟﺘﻘﺮﻳﺒﻲ ) ﻣﻠﻴﻮن (
0–3M 3M - 40M 40M - 200M Above 200 M
Sponsor ID No. رﻗﻢ اﻟﺤﺎﺳﺐ اﻵﱄ
Company Headquarters )National Address (WASEL ﻋﻨﻮان اﻟﱪﻳﺪ اﻟﻮﻃﻨﻲ )واﺻﻞ( ﻣﻘﺮ اﻟﴩﻛﺔ و ﺑﺮﻳﺪ واﺻﻞ
and Wasel address إﺳﻢ
Street رﻗﻢ
Area Building #اﳌﻨﻄﻘﺔ
Name اﻟﺸﺎرع اﳌﺒﻨﻰ
إﺳﻢ
City Districtاﳌﺪﻳﻨﺔ P.O.Box ص.ب
Name اﻟﺤﻲ
اﻟﺮﻣﺰ اﻟﺮﻣﺰ
Country Postalاﻟﺪوﻟﺔ Additional
Codeاﻟﱪﻳﺪي
Code اﻹﺿﺎﰲ
Service Number رﻗﻢ اﻟﺨﺪﻣﺔ
Exp.Date ﺗﺎرﻳﺦ اﻻﻧﺘﻬﺎء
Contact Information Email اﻟﱪﻳﺪ اﻻﻟﻜﱰوﻲﻧ ﻣﻌﻠﻮﻣﺎت اﻻﺗﺼﺎل
Tel اﻟﻬﺎﺗﻒ
Source of income ﻣﺼﺪر اﻟﺪﺧﻞ
Number of Employees ﻋﺪد اﳌﻮﻇﻔﻦﻴ
General Manager Name اﺳﻢ اﳌﺪﻳﺮ اﻟﻌﺎم
External Auditors اﳌﺮاﻗﺒﻮن اﻟﺨﺎرﺟﻴﻮن )ان وﺟﺪ(
)(If Available
Bank Account Details ﻣﻌﻠﻮﻣﺎت اﻟﺤﺴﺎب اﻟﺒﻨﻲﻜ
Account Name اﺳﻢ اﻟﺤﺴﺎب
Bank Name اﺳﻢ اﻟﺒﻨﻚ
Account No. رﻗﻢ اﻟﺤﺴﺎب
(IBAN) Number رﻗﻢ اﻵﺑﻴﺎن
Swift Code رﻗﻢ اﻟﺴﻮﻳﻔﺖ
اﻟﺮﻗﻢ اﻟﴬﻳﺒﻲ VAT No. 300189677400003
1
اﻟﺮﻗﻢ اﳌﻮﺣﺪ U.No. 920003655
ﺧﺎﺿﻌﺔ ﻟﺮﻗﺎﺑﺔ وإﺷﺮاف اﻟﺒﻨﻚ اﻟﻤﺮﻛﺰي اﻟﺴﻌﻮدي ،رﻗﻢ اﻟﱰﺧﻴﺺ ت م ن 20106 / 29/
Shareholders info ﻣﻌﻠﻮﻣﺎت اﳌﺴﺎﻫﻤﻦﻴ
Name اﻻﺳﻢ
رﻗﻢ
Nationality IDاﻟﺠﻨﺴﻴﺔ Shares % ﻧﺴﺒﺔ اﻟﺘﻤﻠﻚ
No. اﻟﻬﻮﻳﺔ
Name اﻻﺳﻢ
ID رﻗﻢ
Nationality No.اﻟﺠﻨﺴﻴﺔ ﻧﺴﺒﺔ اﻟﺘﻤﻠﻚ
Shares %اﻟﻬﻮﻳﺔ
Name اﻻﺳﻢ
رﻗﻢ
Nationality IDاﻟﺠﻨﺴﻴﺔ Shares % ﻧﺴﺒﺔ اﻟﺘﻤﻠﻚ
No. اﻟﻬﻮﻳﺔ
Name اﻻﺳﻢ
رﻗﻢ
Nationality IDاﻟﺠﻨﺴﻴﺔ Shares % ﻧﺴﺒﺔ اﻟﺘﻤﻠﻚ
No. اﻟﻬﻮﻳﺔ
Are any of the owners, shareholders, Board ﻫﻞ أي ﻣﻦ اﳌﻼك أو اﻋﻀﺎء ﻣﺠﻠﺲ اﻻدارة
?member considered a Politically Exposed Person Yes Noﻧﻌﻢ ﻻ ﻣﻦ اﻻﺷﺨﺎص اﳌﻜﺸﻮﻓﻦﻴ ﺳﻴﺎﺳﻴﺎً؟
Note: Additional Names can be provided separately ﻣﻠﺤﻮﻇﺔ :ﻤﻳﻜﻦ ﺗﻘﺪﻳﻢ أﺳﺎﻤء إﺿﺎﻓﻴﺔ ﰲ اﺳﺘﺎﻤرة ﻣﺴﺘﻘﻠﺔ.
PEP Definition : اﻟﺸﺨﺺ اﻟﺴﻴﺎﳼ اﳌﻌﺮض ﻟﻠﻤﺨﺎﻃﺮ :اﻟﺸﺨﺺ اﳌﻜﻠﻒ ﻤﺑﻬﺎﻤت ﻋﺎﻣﺔ ﻋﻠﻴﺎ ﰲ اﳌﻤﻠﻜﺔ أو دوﻟﺔ أﺟﻨﺒﻴﺔ أو ﻣﻨﺎﺻﺐ إدارﻳﺔ ﻋﻠﻴﺎ
Person in charge of a Senior public position in the kingdom or foreign company or an أووﻇﻴﻔﺔ ﰲ إﺣﺪى اﳌﻨﻈﺎﻤت اﻟﺪوﻟﻴﺔ ،وﻳﺸﻤﻞ ذﻟﻚ اﳌﻨﺎﺻﺐ أو اﻟﻮﻇﺎﺋﻒ اﻟﺘﺎﻟﻴﺔ
international organization, أ -رؤﺳﺎء اﻟﺪول أو اﻟﺤﻜﻮﻣﺎت ،وﻛﺒﺎر اﻟﺴﻴﺎﺳﻴﻦﻴ أواﳌﺴﺆوﻟﻦﻴ اﻟﺤﻜﻮﻣﻴﻦﻴ أو اﻟﻘﻀﺎﺋﻴﻦﻴ أو اﻟﻌﺴﻜﺮﻳﻦﻴ ،وﻛﺒﺎراﳌﺴﺆوﻟﻦﻴ اﻟﺘﻨﻔﻴﺬﻳﻦﻴ
ﰲ اﻟﴩﻛﺎت اﻟﺘﻲ ﻤﺗﻠﻜﻬﺎ اﻟﺪول ،واﳌﺴﺆوﻟﻮن اﻟﺒﺎرزون ﰲ اﻷﺣﺰاب اﻟﺴﻴﺎﺳﻴﺔ.
ب -رؤﺳﺎء و ﻣﺪﻳﺮ واﳌﻨﻈﺎﻤت اﻟﺪوﻟﻴﺔ وﻧﻮاﺑﻬﻢ وأﻋﻀﺎء ﻣﺠﻠﺲ اﻹدارة ،أوأي وﻇﻴﻔﺔ ﻣﺎﻤﺛﻠﺔ
Board of Directors Details ﻣﻌﻠﻮﻣﺎت ﻣﺠﻠﺲ اﻹدارة
Name اﻻﺳﻢ
رﻗﻢ
Nationality IDاﻟﺠﻨﺴﻴﺔ Position اﳌﻨﺼﺐ
No. اﻟﻬﻮﻳﺔ
Name اﻻﺳﻢ
ID رﻗﻢ
Nationality No.اﻟﺠﻨﺴﻴﺔ Position اﳌﻨﺼﺐ
اﻟﻬﻮﻳﺔ
Name اﻻﺳﻢ
رﻗﻢ
Nationality IDاﻟﺠﻨﺴﻴﺔ Position اﳌﻨﺼﺐ
No. اﻟﻬﻮﻳﺔ
Name اﻻﺳﻢ
رﻗﻢ
Nationality IDاﻟﺠﻨﺴﻴﺔ اﳌﻨﺼﺐ
No. Positionاﻟﻬﻮﻳﺔ
Note: Additional Names can be provided separately ﻣﻠﺤﻮﻇﺔ :ﻤﻳﻜﻦ ﺗﻘﺪﻳﻢ أﺳﺎﻤء إﺿﺎﻓﻴﺔ ﰲ اﺳﺘﺎﻤرة ﻣﺴﺘﻘﻠﺔ.
For Official Use Only Customer Name is not included in UNSCR list Account No:..............................................................
( To be completed by
) Wataniya Staff Opened by:.................................................................................. Broker or Agent name:.................................................................................. Date..................................
Required Documents اﳌﺴﺘﻨﺪات اﳌﻄﻠﻮﺑﺔ
- CR Copy - Owner's ID - Offer Signed & stamped -ﺻﻮرة ﻣﻦ اﻟﺴﺠﻞ اﻟﺘﺠﺎري -ﻫﻮﻳﻪ اﳌﺎﻟﻚ -ﻋﺮض اﻟﺴﻌﺮ ﻣﻮﻗﻊ وﻣﺨﺘﻮم
)- VAT Registration (if Available -ﺗﺴﺠﻴﻞ ﴐﻳﺒﺔ اﻟﻘﻴﻤﺔ اﳌﻀﺎﻓﺔ )إن وﺟﺪ(
Authorized Signatories اﳌﻔﻮﺿﻮن ﺑﺎﻟﺘﻮﻗﻴﻊ
Name اﻻﺳﻢ
رﻗﻢ
Nationality IDاﻟﺠﻨﺴﻴﺔ Position اﳌﻨﺼﺐ
No. اﻟﻬﻮﻳﺔ
Name اﻻﺳﻢ
رﻗﻢ
Nationality IDاﻟﺠﻨﺴﻴﺔ Position اﳌﻨﺼﺐ
No. اﻟﻬﻮﻳﺔ
* Note: This "KYC" form should be signed by one of the Authorized Signatories. * ﻣﻼﺣﻈﺔ :ﻳﺠﺐ ﺗﻮﻗﻴﻊ ﻤﻧﻮذج " "KYCﻫﺬا ﻣﻦ ﺧﻼل أﺣﺪ اﳌﻮﻗﻌﻦﻴ اﳌﻌﺘﻤﺪﻳﻦ.
**Note: If this form is signed by unauthorized signetory, then an Authorization Letter ** ﻣﻼﺣﻈﺔ :إذا ﺗﻢ ﺗﻮﻗﻴﻊ ﻫﺬا اﻟﻨﻤﻮذج ﻣﻦ ﻗﺒﻞ اﳌﻮﻗﻊ ﻏﺮﻴ اﳌﴫح ﺑﻪ ،ﻓﻴﺠﺐ ﺗﻘﺪﻳﻢ ﺧﻄﺎب ﺗﻔﻮﻳﺾ.
must be provided.
* ﻣﻼﺣﻈﺔ :ﻳﺮﺟﻰ إرﻓﺎق رﻗﻢ اﻟﻬﻮﻳﺔ /اﻹﻗﺎﻣﺔ ﻟﻠﺸﺨﺺ اﻟﺬي وﻗﻊ ﻋﲆ ﻫﺬا اﻟﻨﻤﻮذج.
* Note: Please, attach the ID/IQAMA of the person who signed this form.
اﻟﺮﻗﻢ اﻟﴬﻳﺒﻲ VAT No. 300189677400003
2
اﻟﺮﻗﻢ اﳌﻮﺣﺪ U.No. 920003655
ﺧﺎﺿﻌﺔ ﻟﺮﻗﺎﺑﺔ وإﺷﺮاف اﻟﺒﻨﻚ اﻟﻤﺮﻛﺰي اﻟﺴﻌﻮدي ،رﻗﻢ اﻟﱰﺧﻴﺺ ت م ن 20106 / 29/
Contact Person ﻣﺴﺆول اﻹﺗﺼﺎل
ﻣﺴﺆول اﻹﺗﺼﺎل اﻟﺜﺎﻲﻧ ﻣﺴﺆول اﻹﺗﺼﺎل اﻷول
Second Contact Person First Contact Person
Full Name اﻻﺳﻢ ﻛﺎﻣﻞ
Position اﳌﻨﺼﺐ
Nationality اﻟﺠﻨﺴﻴﺔ
ID No. رﻗﻢ اﻟﻬﻮﻳﺔ
Country of Residence دوﻟﺔ اﻹﻗﺎﻣﺔ
Email اﻟﱪﻳﺪ اﻻﻟﻜﱰوﻲﻧ
Tel. اﻟﻬﺎﺗﻒ
Mob. رﻗﻢ اﻟﺠﻮال
Note: Additional Names can be provided separately ﻣﻠﺤﻮﻇﺔ :ﻤﻳﻜﻦ ﺗﻘﺪﻳﻢ أﺳﺎﻤء إﺿﺎﻓﻴﺔ ﰲ اﺳﺘﺎﻤرة ﻣﺴﺘﻘﻠﺔ.
Note: Please, attach ID copies of the Contact Persons ﻣﻠﺤﻮﻇﺔ :اﻟﺮﺟﺎء ارﻓﺎق ﺻﻮرة ﻫﻮﻳﺎت اﺷﺨﺎص اﻻﺗﺼﺎل
Consent Statement Enquiry and Data sharing for insurance إﻗﺮار اﻻﺳﺘﻌﻼم واﻹﻓﺼﺎح ﻋﻦ ﺑﻴﺎﻧﺎت اﻟﻌﻤﻴﻞ اﻟﺨﺎص ﺑﴩﻛﺎت اﻟﺘﺄﻣﻦﻴ
I the Hereby, undersigned (Agent/Authorized person (on behalf ﺑﻬﺬا أﻧﺎ اﳌﻮﻗﻊ أدﻧﺎه )وﻛﻴﻞ/أو ﺷﺨﺺ ﻣﻔﻮض ﺑﺎﻟﻨﻴﺎﺑﺔ ﻋﻦ
of the Business/Company) agree to provide Wataniya Insurance اﻟﴩﻛﺔ/اﳌﺆﺳﺴﺔ( أواﻓﻖ ﻋﲆ ﺗﺰوﻳﺪ ﴍﻛﺔ اﻟﻮﻃﻨﻴﺔ ﻟﻠﺘﺄﻣﻦﻴ ﺑﺄي ﻣﻌﻠﻮﻣﺎت
Company with any information that it requires for issuing an أو ﺑﻴﺎﻧﺎت ﺗﻄﻠﺒﻬﺎ ﻣﻨﻲ ﻹﺻﺪار ﺑﻮﻟﻴﺼﺔ اﻟﺘﺄﻣﻦﻴ ﻟﺪى اﻟﴩﻛﺔ و/أو ﳌﺮاﺟﻌﺘﻪ و/أو
insurance policy and/or auditing and/or administering my ﻹدارﺗﻪ وأﻓﻮض اﻟﴩﻛﺔ ﺑﺄن ﺗﺤﺼﻞ ﻋﲆ ﻣﺎ ﻳﻠﺰم أو ﺗﺤﺘﺎج إﻟﻴﻪ ﻣﻦ ﺑﻴﺎﻧﺎت أو
accounts and facilities therewith.
ﻣﻌﻠﻮﻣﺎت ،ﺗﺨﺼﻨﻲ أو ﺗﺨﺺ ﺣﺴﺎﻲﺑ اﳌﺬﻛﻮر أو أي ﺣﺴﺎب آﺧﺮ ﻳﻜﻮن ﻟﺪى
اﻟﴩﻛﺔ.
I authorize it to obtain, collect, disclose and share any
ﻛﺎﻤ أواﻓﻖ ﻋﲆ أن ﺗﻔﺼﺢ اﻟﴩﻛﺔ ﻋﻦ اﳌﻌﻠﻮﻣﺎت اﻟﺨﺎﺻﺔ ﻲﺑ ﻋﻦ أي ﻣﻌﻠﻮﻣﺎت
information as it deems necessary or in need for issuing an
insurance policy of all types (active and closed) and/or any other ﺗﺘﻌﻠﻖ ﺑﺒﻮﻟﻴﺼﺔ اﻟﺘﺄﻣﻦﻴ ﺑﺄﻧﻮاﻋﻬﺎ ،ﺳﻮا ًء ﻓﻌﺎﻟﻪ أو ﻣﻨﺘﻬﻴﺔ ،وﻋﻦ أي اﻟﺘﺰام
)financial obligation from/to the Saudi Credit Bureau (SIMAH ﻣﺎدي ﻳﱰﺗﺐ ﻋﲇ ،أو أي ﺣﺴﺎب أﺧﺮ ﻳﻜﻮن ﻟﺪى اﳌﻔﻮض ،ﻟﻠﴩﻛﺔ اﻟﺴﻌﻮدﻳﺔ
through the membership agreement signed with the company. ﻟﻠﻤﻌﻠﻮﻣﺎت اﻻﺋﺘﺎﻤﻧﻴﺔ )ﺳﻤﺔ( ﻣﻦ ﺧﻼل اﺗﻔﺎﻗﻴﺔ اﻟﻌﻀﻮﻳﺔ اﳌﻮﻗﻌﺔ ﻣﻊ
اﻟﴩﻛﺔ.
Customer Name:....................................................................................................... أﺳﻢ اﻟﻌﻤﻴﻞ أواﻟﻮﻛﻴﻞ..................................................................................................:
Signature:..................................................................................................................... اﻟﺘﻮﻗﻴﻊ............................................................................................................................:
Date: / / / / اﻟﺘﺎرﻳﺦ.:
Stamp اﻟﺨﺘﻢ
اﻟﺮﻗﻢ اﻟﴬﻳﺒﻲ VAT No. 300189677400003
3
اﻟﺮﻗﻢ اﳌﻮﺣﺪ U.No. 920003655
ﺧﺎﺿﻌﺔ ﻟﺮﻗﺎﺑﺔ وإﺷﺮاف اﻟﺒﻨﻚ اﻟﻤﺮﻛﺰي اﻟﺴﻌﻮدي ،رﻗﻢ اﻟﱰﺧﻴﺺ ت م ن 20106 / 29/
