0001/E11/09/2015 You can open 3 free accounts : a current account, a savings account and a trading account with maximum 3 accountholders : in this case, please use a copy of this document.
You would like to hold one of the following with Keytrade Bank SA/NV, Bld du Souverain/Vorstlaan 100, B-1170 Brussels: Accountholder 1 bank card (Bancontact / Mister Cash - Maestro, free of charge)
Accountholder 2 bank card (Bancontact / Mister Cash - Maestro, free of charge)
To be issued a bank card, you must be a Belgian resident. Debit cards are issued only when one of your accounts presents a credit balance of at least €50. The PIN and the card are sent to your postal address. If you choose a bank card, by signing this document, you declare that you have read, understood and accepted the Specific Conditions debit cards, which can be found at the Document Centre at www.keytradebank.be.
To apply for a Visa or American Express card, complete online the application form which you can find at www.keytradebank.be We do not open accounts for «US persons».
(1) If you are not a Belgian resident, you also need to complete the "Withholding Tax Certificate" document, which you can find at www.keytradebank.be. (2) For Belgian residents it’s the National Register number. For non-Belgian residents, please visit the website of the European Commission:
https://ec.europa.eu/taxation_customs/tin/tinByCountry.html?locale=en * Warning, the account cannot be used as third-party account.
1. PERSONAL DATA (all details are compulsory)
ACCOUNT HOLDER 1 Mr Mrs Miss Mr Mrs Miss
Language French Dutch
Male Female Male Female
English Surname
First name(s) Gender
Civil status SingleDivorced Married Live-in partner
Personal Business* VAT/company number: ... Commercial name: ... Personal Business* VAT/company number: ... Commercial name: ... Separated Widow(er)
Surname and first name of spouse or live-in partner:
...
Single Married Live-in partner
Divorced Separated Widow(er)
Surname and first name of spouse or live-in partner:
... Official domicile1 Street ... Nr ... Box ... Postcode... Town/City ... Country ... Street ... Nr ... Box ... Postcode... Town/City ... Country ... Street ... Nr ... Box ... Postcode... Town/City ... Country ... Street ... Nr ... Box ... Postcode... Town/City ... Country ... Postal address
if different from official domicile
Country of tax residence if different from official domicile Mobile number
Telephone number E-mail address Date of birth (DD/MM/YYYY) Place and Country of birth Nationality
Other Nationalities Identity card number National Register identification number or Tax identification number2
Purpose of bank account Valid until
(DD/MM/YYYY)
ACCOUNT HOLDER 2
French Dutch English
(3) A person who holds or has held a political mandate or a public position on a regional, national or international level as head of state, minister, Member of Parliament, leader of a political party represented in government, senior civil servant (the executive, including the army, and the judiciary), manager of a national public body, senior politician or senior official of an international or upranational organisation, such as the EU, NATO or the UN.
(*) Make your choice from the attached list with different sectors; write down the corresponding code. (**) Make your choice from the attached list with liberal professions; write down the corresponding code
ACCOUNT HOLDER 1
Do you hold, or have you held, any political or public office at regional, national or international level?
If yes:
Exact title of office or position:
... Decription and role of office/position:
... Date on which office was taken up: ... Date on which office will be relinquished: ... Does the same apply to one of your parents, your children or your partner?
If yes:
Name of person: ... Relationship to you: ... Exact title of office or position:
... Decription and role of office/position:
... Date on which office was taken up: ... Date on which office will be relinquished: ...
yes no
yes no
Do you hold, or have you held, any political or public office at regional, national or international level?
If yes:
Exact title of office or position:
... Decription and role of office/position:
... Date on which office was taken up: ... Date on which office will be relinquished: ... Does the same apply to one of your parents, your children or your partner?
If yes:
Name of person: ... Relationship to you: ... Exact title of office or position:
... Decription and role of office/position:
... Date on which office was taken up: ... Date on which office will be relinquished: ...
yes no
yes no
Occupation / Business
Politically engaged person3
Inside information
ACCOUNT HOLDER 2
Employee
Occupation: ... Code for sector of activity (*) : ... Employer ...
Worker
Occupation: ... Code for sector of activity (*) : ... Employer ...
Manager
Occupation: ... Code for sector of activity (*) : ... Employer ... Employee
Occupation: ... Code for sector of activity (*) : ... Employer ...
Worker
Occupation: ... Code for sector of activity (*) : ... Employer ...
Manager
Occupation: ... Code for sector of activity (*) : ... Employer ...
Civil servant
Occupation: ... Code for sector of activity (*) : ... Employer ...
Self-employed
Code for sector of activity (*) : ... Company name: ... Company number: ...
Liberal profession
Student
Occupation... Code for Liberal profession (**): ... Company number (if applicable): ...
No occupation (please circle as appropriate and complete) Retired / Unemployed / Living off one’s investments / Stay-at-home-parent Since (MM/YYYY): ... Last professional activity carried out: ... ...
Civil servant
Occupation: ... Code for sector of activity (*) : ... Employer ...
Self-employed
Code for sector of activity (*) : ... Company name: ... Company number: ...
Liberal profession
Student
Occupation... Code for Liberal profession (**): ... Company number (if applicable): ...
No occupation (please circle as appropriate and complete) Retired / Unemployed / Living off one’s investments / Stay-at-home-parent Since (MM/YYYY): ... Last professional activity carried out: ... ...
Are you likely to obtain inside information on financial markets?
If yes, wich securities (Issuer and ISIN code)?: ... ...
yes no
Are you likely to obtain inside information on financial markets?
If yes, wich securities (Issuer and ISIN code)?: ... ...
2. PROXY HOLDER
PROXY HOLDER 1 Mr. Mrs. Miss
Male Female Male Female
Surname First name Gender
Civil status Single
Married Live-in partner
Divorced Separated Widow(er)
Surname and first name of spouse or live-in partner:
...
Single Married Live-in partner
Divorced Separated Widow(er)
Surname and first name of spouse or live-in partner:
... Official domicile Street: ... Nr ... Box ... Postcode ... Town/City... Country ... Street: ... Nr ... Box ... Postcode ... Town/City... Country ... Street: ... Nr ... Box ... Postcode ... Town/City... Country ... Street: ... Nr ... Box ... Postcode ... Town/City... Country ... Postal address
if different from official domicile
Mobile number Telephone number E-mail address Date of birth (DD/MM/YYYY) Place and Country of birth Nationality
Other Nationalities Identity card number
National Register number Valid until
(DD/MM/YYYY)
PROXY HOLDER 2 Mr. Mrs. Miss
Occupation / Business
Employee
Occupation: ... Code for sector of activity (*) : ... Employer ...
Worker
Occupation: ... Code for sector of activity (*) : ... Employer ...
Manager
Occupation: ... Code for sector of activity (*) : ... Employer ...
Civil servant
Occupation: ... Code for sector of activity (*) : ... Employer ...
Self-employed
Code for sector of activity (*) : ... Company name: ... Company number: ...
Liberal profession
Student
Occupation... Code for Liberal profession (**): ... Company number (if applicable): ...
No occupation (please circle as appropriate and complete) Retired / Unemployed / Living off one’s investments / Stay-at-home-parent Since (MM/YYYY): ... Last professional activity carried out: ... ...
Civil servant
Occupation: ... Code for sector of activity (*) : ... Employer ...
Self-employed
Code for sector of activity (*) : ... Company name: ... Company number: ...
Liberal profession
Student
Occupation... Code for Liberal profession (**): ... Company number (if applicable): ...
No occupation (please circle as appropriate and complete) Retired / Unemployed / Living off one’s investments / Stay-at-home-parent Since (MM/YYYY): ... Last professional activity carried out: ... ...
Employee
Occupation: ... Code for sector of activity (*) : ... Employer ...
Worker
Occupation: ... Code for sector of activity (*) : ... Employer ...
Manager
Occupation: ... Code for sector of activity (*) : ... Employer ...
(*) Make your choice from the attached list with different sectors; write down the corresponding code. (**) Make your choice from the attached list with liberal professions; write down the corresponding code
I declare and acknowledge that:
- I am not a «US person». The term US person must be interpreted in accordance with the American law in force and I declare that I am fully responsible for ascertaining whether I am categorised or not as a US person. If in any doubt, I must contact a specialised tax adviser.
If I was to be categorised as a US person during the service offer, I must immediately notify Keytrade Bank. If I do not notify the Bank in time, I will be responsible for any prejudice caused by this. As a result of American regulation and legislation, Keytrade Bank does not provide any services to US persons and therefore will accordingly be authorised to bring an end to its customer relationship.
Information communicated to Keytrade Bank:
- The information provided when the bank account is opened, in this document and appendices, is accurate, up-to-date and complete.
- The credit balances on the account are not and shall not be of illegal origin, nor are they and nor shall they be used for the purposes of money laundering or the financing of terrorism. - The accountholder(s) is (are) the effective beneficiary of the credit amounts which shall be deposited in the accounts and I undertake to notify Keytrade Bank immediately if this is not or were no longer to be the case, and to send it all useful information with a view to identification of the effective beneficiary (beneficiaries).
Remote contract:
- I have been advised that, in the case of conclusion of a remote contract for opening an account, the accountholder(s) have a period of 14 calendar days following the opening of the account in which to waive the contract. By using Keytrade Bank products or services during the period, I am expressing my consent to execution of the contract before expiry of the waiver period. Methods of communication:
- I have chosen to receive by e-mail, via the transactional site, via the website www.keytradebank.be or, as Keytrade Bank may choose, by any other appropriate means of remote communica-tion, any information which Keytrade Bank is statutorily required to send me or considers appropriate to send me in the context of our relationship5.
Orders on financial instruments:
- I accept responsibility for all risks relating to orders on financial instruments submitted for and on my behalf to Keytrade Bank, on the understanding that Keytrade Bank may not be held liable for the suitability of my investment decisions or the financial outcome of the orders.
Protection of personal data:
- The personal information collected by Keytrade Bank when the account is opened or during the banking relationship shall be processed by Keytrade Bank, the party responsible for the processing of these data, in accordance with the regulation on the protection of privacy. They shall mainly be processed for the purposes of managing the bank account, control, preparation of market analyses, statistics, internal tests and studies. They may also be processed for canvassing and direct marketing relating to products promoted by the Bank, by companies belonging to the group of which the Bank forms part or, where appropriate, by third parties, but in the latter case, without communication of these data to these third parties (barring objection when the account is opened). More detailed information about the collection, registration, processing and, where applicable, communication of these data to third parties and about the right of consultation, correction and objection is contained in the section entitled "Private life" in the General Terms and Conditions of Keytrade Bank.
- My telephone conversations with Keytrade Bank may be recorded by Keytrade Bank, in accordance with the section entitled "Proof" of the General Terms and Conditions, for evidentiary purposes (in particular, but without being limited to, with regard to me or the supervisory and/or legal authorities), and that these recordings are kept for a period necessary for achievement of the aims sought.
- Article 322, §3 of the 1992 Income Tax Code, and the Royal Decree of 17 July 2013 require Keytrade Bank to communicate, once a year, data concerning its customers and their contracts to the Central Point of Contact held by the National Bank of Belgium (NBB), Boulevard de Berlaimont/Berlaimontlaan 14, B-1000 Brussels (hereinafter the "CPC"). Detailed information about the data sent to the CPC, about the use that may be made of the data and about the rights of the undersigned on this subject is available on our website www.keytradebank.be.
Contractual documents:
- I have read the following documents available at any time at www.keytradebank.be or on the transactional site, have understood them and accept them unconditionally: * the General Terms and Conditions, the Fees and Conditions, Interest, Exchange Rates for Payment Transactions and Offer of Payment Products and Services, * the terms and conditions of use of the website www.keytradebank.be,
* the key information for savers regarding the Azur Savings Account and the key information for savers regarding the High Fidelity Savings Account, , along with the complete regulations of Keytrade Bank concerning these accounts.
These documents are e-mailed to you when the account is opened and are also available, on request and free of charge, from Keytrade Bank. Changes:
- I undertake to immediately notify the Bank of any change in the information provided, particularly any change in (non-) resident status for tax purposes.
PROXY HOLDER 1
Politically engaged person4
Inside information
PROXY HOLDER 2
3. DECLARATION
Do you hold, or have you held, any political or public office at regional, national or international level?
If yes:
Exact title of office or position:
... Decription and role of office/position:
... Date on which office was taken up: ... Date on which office will be relinquished: ... Does the same apply to one of your parents, your children or your partner?
If yes:
Name of person: ... Relationship to you: ... Exact title of office or position:
... Decription and role of office/position:
... Date on which office was taken up: ... Date on which office will be relinquished: ...
yes no
yes no
yes no
Do you hold, or have you held, any political or public office at regional, national or international level?
If yes:
Exact title of office or position:
... Decription and role of office/position:
... Date on which office was taken up: ... Date on which office will be relinquished: ... Does the same apply to one of your parents, your children or your partner?
If yes:
Name of person: ... Relationship to you: ... Exact title of office or position:
... Decription and role of office/position:
... Date on which office was taken up: ... Date on which office will be relinquished: ...
yes no
yes no
Are you likely to know insider information about the financial markets?
if yes, which securities (Issuer and ISIN code)?: ... ...
yes no
Are you likely to know insider information about the financial markets?
if yes, which securities (Issuer and ISIN code)?: ... ...
(4) A person who holds or has held a political mandate or a public position on a regional, national or international level as head of state, minister, Member of Parliament, leader of a political party represented in government, senior civil servant (the executive, including the army, and the judiciary), manager of a national public body, senior politician or senior official of an international or supranational organisation, such as the EU, NATO or the UN.
(5)I acknowledge that I have been advised that in some cases, the applicable regulation allows me the option of receiving certain information in hard copy format or in another format. With regard to its internet bank status, Keytrade Bank's policy is to favour means of communication other than paper, and to only enter into a contractual relationship with customers accepting these methods of communication. By applying to open an account with Keytrade Bank, I accept this policy.
SIGNATURE ACCOUNTHOLDER 1
(in accordance with the identity document) SIGNATURE ACCOUNTHOLDER 2(in accordance with the identity document)
SIGNATURE PROXY HOLDER 1
(in accordance with the identity document) SIGNATURE PROXY HOLDER 2(in accordance with the identity document)
Where did you hear about Keytrade Bank? Press advertising radio television internet Trade fairs Word of mouth mailshot You agree to your personal data being used by Keytrade Bank for commercial purposes and also authorize Keytrade Bank to send you by e-mail commercial communications for the products and services promoted by Keytrade Bank
In the case of the above acceptance, at all times you have the right to object to the use of your personal data for direct marketing purposes and/or the use of your e-mail address for sending advertising communications, by sending an e-mail to [email protected], or a letter to the Legal Department at Keytrade Bank's address.
Have you answered all questions and included all the requisite enclosures?
Your application will only be processed quickly if it is complete. All information shall be treated confidentially.Place and date: ...
By signing this form, the authorised representative confirms their acceptance of the Bank's General Terms and Conditions, and in particular of Article relating to power of attorney.
If you have a promo code, enter it here:
The requisite enclosures with this document, duly completed and signed, are as follows: - A copy of both sides of the identity cards of accountholders AND proxy holder
The copy (both sides, in black and white, A4 format) must be legible and the photo must be clear and recognisable. The date of validity of the identity document must not have expired.
- Recent proof of address (maximum 3 months) of accountholders AND proxy holder for not Begium resident
By way of example, the following are accepted as proof of address: the original of a health insurance company label, a copy of a tax notice of assessment or a copy of a gas, water, electricity or telephone bill dated within the last 3 months at the most.
- The certificate of withholding tax for non-residents (if applicable)
yes no
4. REQUISITE ENCLOSURES
Keytrade Bank nv - sa
Vorstlaan 100 Bld du Souverain B-1170 Brussels, Belgium. T + 32 2 679 90 00 - F + 32 2 679 90 01
[email protected] keytradebank.be
List with sectors of activity & Liberale profession
Agriculture, forestry and fishing Mining and quarrying Manufacturing
Electricity, gas, steam and air conditioning supply 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Water supply; sewerage, waste management and remediation activities Construction
Wholesale and retail trade; repair of motor vehicles and motorcycles Transportation and storage
Accomodation and food service activities Information and communication Financial and insurance activities Real estate activities
Professional, scientific and technical activities Administrative and support service activities
Public administration and defence; compulsory social security Education
Human health and social work activities Arts, entertainment and recreation Other service activities
Activities of households as empoyers; Undifferentiated goods- and services-producing activities of households for own use Activites of extraterritorial organisations and bodies
47730 Dispensing chemist in specialised stores 66191 Activities of bank agents and brokers 66210 Risk and damage evaluation
66220 Intermediation in buying, selling and rental of real estate 68311 Intermediation in buying, selling and rental of real estate
68312 Appraisal services in connection to buying, selling and rental of real estate 69101 Activities of lawyers
69102 Activities of notaries 69103 Activities of bailiffs
69201 Activities of accounting and tax consultancy 69202 Activities of bookkeeping and tax bookkeeping 69203 Activities of auditing
71111 Activities of building architect 71112 Activities of interior decorating
71113 Town and city planning and landscape architecture 71122 Surveying activities
74300 Translation and interpretation activities 75000 Veterinary activities
86210 General medical practice activities 86220 Specialist medical practice activities 86230 Dental practice activities
86904 Activities related to mental health, except psychiatric hospitals and homes 86905 Activities of physiotherapists
86906 Activities of nurses 86907 Activities of midwives 86909 Other human health activities
