Menu
Work
D1 Forms
D1 – Part A
D1 – Part B
D1 – PART C
D1 – PART D
D2 Forms
D2: FINGERPRINT
D1 – PART B: Work, Business and Source of Wealth Information
File is created by
USER
E-mail
D1 – PART B: Work, Business and Source of Wealth Information
Occupation by training
Current Primary occupation
Are you self-employed
Yes
No
Primary business or employer
Nature of business or employer’s business
Registered address of business of employer
Business telephone number
Business fax number
Business or employers website address
If own business, registration number and country
List all companies of which you are currently a shareholder or director
Please provide the details for any privileged or professional licenses that you may hold in any state, (e.g. liquor, real estate, professional, financial services or gambling).
Position / Designation Held
License / Registration / Practice Number
Licensing Authority
Position / Designation Held
License / Registration / Practice Number
Licensing Authority
Have you ever had any disciplinary action taken against you in respect to any of these licences?
Yes
No
If “yes” explain the nature of the action
Income, source of Funds and Source of Wealth
Your estimated gross annual net income (USD)
Your total estimated net worth (personal assets minus personal liabilities, USD)
Main srouce and business activities from which you generate your main source of income
Main geographical jurisdictions in whcih you conduct business
Most important companies / persons with whom you do business
Please provide a summarized statement of how you have accumulated your Total Net Worth by listing the main acquisitions /dispositions and events (continue on additional paper if necessary)
In the table below, please provide the estimated value of your assets and liabilities (Please provide documentary support for these estimations).
Assets
Fixed Assets (eg.property, vehicle, etc.)
Savings / Deposits
Investments(eg:stocks,shares,bonds,debentures,etc)
Others(please specify)
Total
Liabilities
Outstanding Long Term Loans (eg. mortgage, car loan, personal loan, etc)
Outstanding short Term Loans (eg. credit card bills, tax liabilitity)
Others(please specify)
Total
Please provide the personal bank account details from which you will be sending funds to the Government of Dominica
Name of Account
IBAN / BIC Code
Account Number
Bank Name and Address
Have any additional information added at the end of this form on seperate pages.
Yes
Please give details of all schools, or training institutions attended and all qualifications obtained up to the highest level of education you successfully completed.
School 1
Name of school
Qualification / diploma achieved
Address
Start (mm/yyyy)
End (mm/yyyy)
School 2
Name of school
Qualification / diploma achieved
Address
Start (mm/yyyy)
End (mm/yyyy)
School 3
Name of school
Qualification / diploma achieved
Address
Start (mm/yyyy)
End (mm/yyyy)
School 4
Name of school
Qualification / diploma achieved
Address
Start (mm/yyyy)
End (mm/yyyy)
Please give details of your employment history during the last 10 years ( List most recent experience first)
Employment 1
Name of Employer
Position held
Type of business / Industry
Start (mm/yyyy)
End (mm/yyyy)
Reasons for leaving
Address
Employment 2
Name of Employer
Position held
Type of business / Industry
Start (mm/yyyy)
End (mm/yyyy)
Reasons for leaving
Address
Employment 3
Name of Employer
Position held
Type of business / Industry
Start (mm/yyyy)
End (mm/yyyy)
Reasons for leaving
Address
Employment 4
Name of Employer
Position held
Type of business / Industry
Start (mm/yyyy)
End (mm/yyyy)
Reasons for leaving
Address
Employment 5
Name of Employer
Position held
Type of business / Industry
Start (mm/yyyy)
End (mm/yyyy)
Reasons for leaving
Address
Employment 6
Name of Employer
Position held
Type of business / Industry
Start (mm/yyyy)
End (mm/yyyy)
Reasons for leaving
Address
Submit
English
Chinese
Japanese
English