KLIC - Pre-Paid Card Application Form

Product

Personal Information

Gender

Name

Please fill out

Last Name

Please fill out

Second Last Name

Please fill out

Date of Birth

Please fill out

Country of Birth

Identification

ID Type

ID Number

Please fill out

Expiration Date

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Issuing Country

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ID Attachment

Please Attach file requested

Address

Country of Residence

Please fill out

State/Province

Please fill out

City

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Address

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Postal Code

Please fill out

Attach Utility Bill

Please Attach file requested

Contact

Phone Number

Please fill out

Mobile Number

Please fill out

Financial Profile

Occupation

Monthly Income (Aprox.)

Academic Degree

Economic Activity

Name and Address of Company

Years in the Company

Commercial/Banking References

Name of Institution

Relationship/Product

Name of Institution

Relationship/Product

Referral Code

I voluntarily and spontaneously declare, free from any error, force or intent that all the statements and answers I have expressed in this document are correct, true, complete and I authorize The Issuer to verify all the detailed information. In addition, I am obligated to report any changes or updates to information that may affect the statements and answers noted on this form. I declare that I exercise all my activities within the legal norms contemplated in the international and local laws. I also certify that I do not have a residence, I do not work and I do not maintain any type of commercial relationship with Countries of jurisdictions classified as high risk by the Financial Action Task Force (FATF).

All information will be sent through protected channels and handled with strict confidentiality, in accordance with international standards of personal information management.