ࡱ> gif"VbjbjVV4r<<K 44444HHH8<Hu#j"""""""$'b"]4"44H/#|44"":!,"`HT(! "E#0u#!R'|T'"'4"""u#'( :">40B>: 6 4> " "/QUESTIONNAIRE , !"   .// GENERAL INFORMATION ABOUT THE COMPANY10720 :><?0=VW // Name of the company2@0W=0 @5TAB@0FVW // Country of incorporation3 5TAB@0FV9=89 =><5@ B0 40B0 @5TAB@0FVW // Number and date of registration48:>=02G89 >@30= (=09<5=C20==O, A:;04: .../ V<5=0 G;5=V2 28:>=02G>3> >@30=C, :@0W=0 3@><04O=AB20) // Executive Body (name, composition: names of the Executive Body members, their citizenship)5>=B0:B=0 V=D>@<0FVO :><?0=VW (251A09B, :>=B0:B=V =><5@8 B5;5D>=V2, e-mail) // Contact information (website, telephone numbers, e-mail)6A=>2=V 2848 4VO;L=>ABV Main activities7'8 1C;0 :><?0=VO @5>@30=V7>20=0, 284V;5=0, ?5@59<5=>20=0; G8 T :><?0=VO ?@02>=0ABC?=8:>< V=H>W N@848G=>W >A>18? Has the company been reorganized, spun off, renamed; whether the company is the successor of another legal entity?=V B0: (1C4L ;0A:0 CB>G=VBL) // No Yes (please clarify)8'8 7<V=N20;8AO 70 >AB0==V 420 @>:8 CG0A=8:8 (2V4 0%) G8 0:FV>=5@8 (2V4 10%), 48@5:B>@8, G;5=8 =03;O4>2>W @048? Have the participants (from 0%) or shareholders (from 10%), directors, members of the Supervisory Board changed over the past two years?=V B0: (1C4L ;0A:0 CB>G=VBL) // No Yes (please clarify)9'8 ?@0FNT :><?0=VO C B0:8E :@0W=0E/@53V>=0E: !C40=; V2VO; @0:; 0:8AB0=; D30=VAB0=; @0=; V15@VO; >@40=VO; @>AV9AL:0 D545@0FVO; 1V;>@CAL; !(; =5?V4:>=B@>;L=0 B5@8B>@VO #:@0W=8 // Is the company active in these countries/regions: Sudan Libya Iraq Pakistan Afghanistan Iran Liberia Jordan russian federation belarus USA uncontrolled territory of Ukraine =V B0: (1C4L ;0A:0 CB>G=VBL) // No Yes (please clarify)!  " " & $&  ! (UBO) // COMPOSITION OF THE COUNTERPARTY S ASSETS ULTIMATE BENEFICIARY OWNER (UBO)10>2=5 V< O UBO B0 :@0W=0 3@><04O=AB20 // Full name of UBO, citizenship11... B0 :@0W=0 3@><04O=AB20 4>2V@G>3> :5@CNG>3> (O:I> :V=F5289 2;0A=8: T =><V=0;L=8< 2;0A=8:><) // Full name and citizenship of the trustee (if the ultimate owner is a nominal holder)12... CG0A=8:V2 01> 0:FV>=5@V2, O:V 2>;>4VNBL 10% V 1V;LH5 0:FV9, :@0W=0 WE 3@><04O=AB20 // Full names of the participants or shareholders owning 10% or more shares, their country of citizenship130B5@8=AL:0/E>;48=3>20 :><?0=VO/>A=>2=0 :><?0=VO 3@C?8, G0AB8=>N O:>W T 20H0 :><?0=VO (=0720, :@0W=0 @5TAB@0FVW, @5TAB@0FV9=89 =><5@) // Parent / holding company / main company of the group of which your company is a part (name, country of incorporati .HJ , . 0 2 ` v , . Ĵ|iV|O|i@Fpoaaaaaaaaad$Ifgdkd$$Ifl`F1%N t06    44 layt prvTfloaaaaaaaaad$Ifgdkd$$IflF1%N t06    44 layt :HVbvoaaOOOOOO & Fd$Ifgdd$Ifgdkd8$$IflF1%N t06    44 layt  RX"0Vfn & Fd$Ifgdd$Ifgdhd$If^hgd & Fd$IfgdX\vVXBDXڴڥڞzjZFZ'hh~5CJOJQJaJmH sH hh~5CJOJQJaJhh6CJOJQJaJ'hhia5CJOJQJaJmH sH hhia5CJOJQJaJ hhOhhOCJOJQJaJ$hhCJOJQJaJmH sH $hhOCJOJQJaJmH sH $hh~CJOJQJaJmH sH $hh@YCJOJQJaJmH sH   Bd$IfgdBDtZo^^^$d$Ifa$gdkd$$Ifl1F1%N t06    44 laytXZ\x~lnpr2DD0D2D4D6DZDbDDDDJFHHfHjHկ¨կըկըկըscկկhhY^5CJOJQJaJhh5CJOJQJaJhhia5CJOJQJaJU$hhBECJOJQJaJmH sH  hhO$hhY^CJOJQJaJmH sH $hhOCJOJQJaJmH sH hhOCJOJQJaJ hhia'hhia5CJOJQJaJmHsH&Z\bd$Ifgdhkd$$Ifl1%% t0644 laytnpoaaaad$Ifgdkd$$IflF1%N t06    44 laytprx2oaaaad$Ifgdkd$$IflF1%N t06    44 layt 2D4Doaaaad$Ifgdkdi$$IflF1%N t06    44 layton, registration number)  !& // INTERNATIONAL SANCTIONS14'8 70AB>A>2C20;8AL O:VAL <V6=0@>4=V/C:@0W=AL:V A0=:FVW 4> :><?0=VW, C B><C G8A;V 4> 1C4L-O:>W :><?0=VW E>;48=3C/3@C?8 :><?0=V9, 4> O:>W 2E>48BL 20H0 :><?0=VO, WW ?>A04>28E >AV1 (70 25AL G0A 4VO;L=>ABV :><?0=VW)? // Have any international/Ukrainian sanctions been applied against the company, including against any company of the holding/group of companies that includes your company, its officials (for the entire time of the company's activity)?=V B0: (1C4L ;0A:0, CB>G=VBL) // No Yes (please clarify)15'8 1C;> 70AB>A>20=> 1C4L-O:V <V6=0@>4=V/C:@0W=AL:V A0=:FVW 4> UBO? // Have any international/Ukrainian sanctions been applied against UBO?=V B0: (1C4L ;0A:0, CB>G=VBL) // No Yes (please clarify)16'8 A?V2?@0FNT :><?0=VO/ UBO 7 1C4L-O:8<8 >A>10<8, I>4> O:8E 70AB>A>20=V <V6=0@>4=V/C:@0W=AL:V A0=:FVW, C B><C G8A;V SDN, non-SDN (4>3>2V@=V 2V4=>A8=8, C B><C G8A;V 4>3>2V@ ?@> A?V;L=C 4VO;L=VABL, CG0ABL C =5:><5@FV9=8E >@30=V70FVOE, A?V;L=5 ?V4?@8T<AB2>, B>20@8AB2>, A?V;L=0 CG0ABL C 1V7=5AV (2;0A=VABL V=H8E N@848G=8E >AV1), 1C4L-O:V D>@<8 DV=0=AC20==O, AC4>2V AC?5@5G:8, >A>18ABV 2V4=>A8=8)? // Does the company / UBO cooperate with any persons against whom international / Ukrainian sanctions are applied, including SDN, non-SDN (contractual relations, including a joint activity agreement, participation in non-profit organizations, joint venture, society, joint participation in business (ownership of other legal entities), any form of funding, litigation, personal relationships)?=V B0: (1C4L ;0A:0, CB>G=VBL) // No Yes (please clarify) #" // DOCUMENTS1>?VO G8==8E CAB0=>2G8E 4>:C<5=BV2 // Copy of valid constituent documents2>?VW 4>:C<5=BV2, I> ?V4B25@46CNBL ?>2=>2065==O ?@54AB02=8:0 (70 =0O2=>ABV) // Copies of documents confirming the authority of the representative (if any)3@0DVG=0 AB@C:BC@0 2;0A=>ABV :><?0=VW 4> UBO (?>G8=0NG8 7 5%) V7 707=0G5==O< G0AB:8 (?V4?8ACTBLAO 48@5:B>@>< :><?0=VW/:>=B@>;5@>< 01> V=H>N C?>2=>2065=>N >A>1>N) // Graphical structure of the company's ownership to UBO (starting from 5%) indicating the share (signed by the director of the company / inspector or other authorized person) V4?8A C?>2=>2065=>W >A>18 // Signature of authorized person ... 28:>=02FO, B5;. // Full name of an executor, tel.     4D6DDo^$d$Ifa$gdkd $$Ifl F1%N t06    44 laytDDDJFH H\H^H`HbHdHfHlHHd$Ifgdhkd $$Ifl1%% t0644 layt jHlHHHI I,IIIIIJ*J,JbJhJK K$K*K,K2KNMZP\PPPPPPPPPQııııӖzjhhl76CJOJQJaJhh_5CJOJQJaJhl7CJOJQJaJhSqCJOJQJaJhh""CJOJQJaJ$hh""CJOJQJaJmH sH hhOCJOJQJaJ hhO$hhY^CJOJQJaJmH sH $hhOCJOJQJaJmH sH !HHH,IIIIJ*Joaaaaaaad$Ifgdkd@ $$Iflb F1%N t06    44 layt*J,J2JNM\PbPPPPPPPoaaaaaaaaaad$Ifgdkd $$IflF1%N t06    44 layt PPPPPPPPPPPa\\gdSqkd $$Ifl/F1%N t06    44 laytd$Ifgd PPQQ QlQQQssssd$IfgdhkdG $$Ifl1%% t0644 layt$d$Ifa$gdgdSqQQQQlQtQvQzQ|QQQQQQQQZRRRRRDTUUUUUUUVymyZ$h""h""CJOJQJaJmH sH hl7CJOJQJaJh_CJOJQJaJ$hhOCJOJQJaJmH sH  hhOhh""CJOJQJaJ$hh""CJOJQJaJmH sH hhOCJOJQJaJ hh_'hh_5CJOJQJaJmH sH 'hh""5CJOJQJaJmH sH QQQZRRRoaaaad$Ifgdkd $$Ifl`F1%N t06    44 laytRRRDTUUoaaaad$Ifgdkdq $$IflF1%N t06    44 laytUUUUU V"V$VXVVVojjjjjjjj` dgdgdSqkd$$Ifl7F1%N t06    44 layt V VPVVVXVvVxVVVVVVVVVVVVV²£h[Njh[NUh""hl7CJOJQJaJh""h""CJOJQJaJhCJOJQJaJmH sH $h""h""CJOJQJaJmH sH hl7CJOJQJaJh_CJOJQJaJ$h""hl7CJOJQJaJmH sH VVVVVVVVVVgdSq dgd 21h:pl. 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