D1 – PART B: Work, Business and Source of Wealth Information

 


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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