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APPLICATION FORM

I/WE INSTRUCT YOU TO REGISTER THE COMPANY WITH THE FOLLOWING DETAILS:
1. COUNTRY OF INCORPORATION
2. PROPOSED COMPANY NAME
(Please provide three choices in order of preference)
(A)
(B)
(C)
3. NATURE OF BUSINESS
(Please provide full description of the business activities of your intended company, i.e. holding, trading with., marketing, production of..., shipping, insurance, etc. )
Estimated First Year's Annual Turnover (US$)
Expected Value and Number of Incoming Transfers per Month (US$)
Expected Value and Number of Outgoing Transfers per Month (US$)
Geographic Spread of Proposed Business
4. CONTACT DETAILS OF THE APPLICANT
Family Name (Mr / Mrs / Ms )
Given Name
Contact Address
Post Code
Country
Email
Tel
Fax
Mobile
How do you prefer us to contact you?
Tel  / Mobile / Fax / Email / Mail
5. DIRECTORS (tick were appropriate)
Please register the following parties as Director(s)
Please provide Nominee Director(s) for those listed below 
A. Family Name (Mr / Mrs / Ms )
Given Names
Any former name Date of Birth (DD/MM/YY)
Passport / ID Number Nationality
Place of Birth Occupation
Permanent Home Address
Post Code Fax
Tel Email
Country Mobile
B. Family Name (Mr / Mrs / Ms )
Given Names
Any former name Date of Birth (DD/MM/YY)
Passport / ID Number Nationality
Place of Birth Occupation
Permanent Home Address
Post Code Fax
Tel Email
Country Mobile
6. COMPANY SECRETARY AND REGISTERED ADDRESS
DeltaQuest will provide Company Secretary and Registered Address. Should you wish to appoint your own company secretary, please contact DeltaQuest for further information.
7. PROPOSED SHARE CAPITAL OF THE COMPANY
(Visit our web site to see usual capital for particular jurisdiction)
Capital
Number of Shares
Value of one Share
8.SHAREHOLDERS (tick were appropriate)
Please register the following parties as shareholder(s) / Please provide Nominee shareholder(s) for those listed below
A. Family Name (Mr / Mrs / Ms )
(or Name of the Company in case of corporate body)
Given Names
Any former name
Date of Birth (DD/MM/YY) (or date of registration in case of corporate body)
Passport / ID Number (or Registration number in case of corporate body)
Nationality
Place of Birth
Occupation
Permanent Home Address (or registered address in case of corporate body)
Post Code
Country
Tel
Email
Mobile
Fax
Number of shares to be held
B. Family Name (Mr / Mrs / Ms )
(or Name of the Company in case of corporate body)
Given Names
Any former name
Date of Birth (DD/MM/YY) (or date of registration in case of corporate body)
Passport / ID Number (or Registration number in case of corporate body)
Nationality
Place of Birth
Occupation
Permanent Home Address (or registered address in case of corporate body)
Post Code
Country
Tel
Email
Mobile
Fax
Number of shares to be held
9. CLIENT - DUE DILIGENCE INFORMATION
VERY IMPORTANT! AS PROVIDERS OF CORPORATE SERVICES, DELTAQUEST IS REQUIRED BY LAW TO CLEARLY IDENTIFY ITS CLIENTS AND THE BENEFICIAL OWNERS OF THE COMPANY BEFORE ENGAGING ITSELF INTO ANY SERVICES. THE INFORMATION PROVIDED BY CLIENT IN THE ABOVE QUESTIONNAIRE IS ONLY FOR DELTAQUEST'S INTERNAL USE AND WILL BE KEPT CONFIDENTIAL AT ALL TIMES SUBJECT TO THE APPLICABLE LAWS. THIS INFORMATION IS NOT PART OF ANY PUBLIC RECORD, SO THE SECRECY OF DELTAQUEST'S CLIENTS REMAINS COMPLETELY PROTECTED.

DELTAQUEST WILL CONSIDER THE PERSON(S) INDICATED IN THE FIELD BELOW TO BE ITS CLIENT(S) AND/OR THE BENEFICIAL OWNER(S) OF THE COMPANY ORDERED. DELTAQUEST WILL NOT TAKE ANY FURTHER INSTRUCTIONS IN RELATION TO THIS COMPANY FROM ANY OTHER PERSONS EXCEPT THE ONE(S) INDICATED HERE, UNLESS OTHERWISE COMMUNICATED TO DELTAQUEST IN WRITING BY BENEFICIAL OWNER(S).
(!) Documentary proof. Please PROVIDE the following documents:
- certified or notarized copy of Your passport;
- original proof of address;*
- banker's reference;**
- DULY COMPLETED and signed Terms & Conditions (by fax or submitted on line);
- in cases where shareholders and directors are corporate bodies, full apostilled set of corporate documents and certificate of good standing.

* A proof of address is any recent document, where the name and residential address of the person is indicated. It can be a recent utility bill, telephone bill, credit card or bank statement or other similar document.
** You can obtain an original Bank Reference from Your bank and send it to us or ask your bank to send it to us directly.

All of the above listed documents should be sent to us by fax or e-mail first and thereafter by mail. We will not be able to complete Your order before we are in receipt of THE above documents.

DeltaQuest Management Ltd
P.O. Box 57216, Limassol 3313, Cyprus
Fax : +357-25-761160
E-mail: info@mydeltaquest.com
10. METHOD OF PAYMENT
Wire/Telegraphic Transfer
Cash
Bankers Draft
Credit Card
11. PLEASE ADVISE WHERE WE SHOULD DELIVER THE CORPORATE DOCUMENTS
Same as CONTACT PERSON whose details appear in Section 4
If YES Please tick here OR TO:

Full Name (Mr / Mrs / Ms )
Contact Address
Post Code
Tel
Country
Fax
Email
Mobile
All company documents will be delivered by COURIER unless otherwise instructed
Special Instructions
12. DECLARATION

I/We (name/s of the persons who will sign this questionnaire) Do Hereby Declare That All Details Given Above Are True And Accurate, That I/We Authorise And Appoint DELTAQUEST To Act As My/Our Representative In Accordance With The Instructions Detailed Above.  I/We Agree To Abide by the laws of the country of incorporation of the company and conditions of Business as Specified. I/We Hereby Warrant That I/We Will Indemnify And Hold Harmless Deltaquest And Any Person Who May Be A Shareholder, Director, Employee Or Associate Of DeltaQuest in respect of all legal actions, claims or demands, damages, losses  or costs of whatsoever nature, incurred by deltaquest in connection with our above instructions.  I/We Also Accept Responsibility for timely Payment of the Agreed Initial, regular and Annually Recurring Charges and fees Billed by Deltaquest as provided by the  terms and conditions of business, which effectively constitute a services contract between myself/ourselves and deltaquest.
Full Name
Date
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Download the Application Form:

Adobe® Acrobat® PDF (*.pdf)

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