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Form for contracting services*

1. Customer Information (To be completed by individuals or company representatives).

• Note: Please provide supporting documentation for all information provided. (Copy of Passport (s), Identification (s), Assembly that grants power of signature, as well as any other document that proves your identity and quality).

2. Customer information (To be completed by companies):

Note: please provide supporting documentation for all the information provided (copy of incorporation documents Tax Id number or R.N.C., Copy of Mercantile Registry. Proof of Ownership by the Final Beneficiaries, copy of the identification document of the final beneficiaries , as well as any other that supports the information contained in this document.

3. Contact information:

4. Source of funds

5.Description of activities carried out by the client:

6. Scope(s) of services required:

• Note: This form must be completed and/or updated by all new and existing clients in accordance with Law No. 155-17, Against Money Laundering and Terrorism Financing, promulgated on June 1, 2017 in the Dominican Republic.

By the Client

Thanks for submitting!

Main office

Module 206, Plaza la Trinitaria,

Av. Juan Pablo Duarte Esq. Calle Maimón, Santiago de los Caballeros, República Dominicana

Office in the National District

C/o Oficina Legal & Processes,Calle Máximo Avilés Blonda 34,Plaza Madelta IV, Suite No. 206, Ens. Julieta, Santo Domingo, D. N.República Dominicana

International mail address

EPS No. i-5878 P.O. Box 02-5488, Miami, Fl, 33102-5488,Miami

Estados Unidos de América

809-276-2400 / 809-276-2401

Copyright © 2023 by Pérez & Robles, Technical Office of Intellectual and Industrial Property

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