Onboarding application form for individuals

1. CLIENT DETAILS

TITLE *

FIRST NAME

SURNAME

NATIONALITY *

PLACE & COUNTRY OF BIRTH *

DATE BIRTH (DD/MM/YYYY)

NID/PASSPORT

LANDLINE PHONE NUMBER

MAIN MOBILE NUMBER

MAIN EMAIL ADDRESS

STREET ADDRESS

CITY/TOWN

STATE/PROVINCE

ZIP/POSTAL CODE

COUNTRY *

1B. CLIENT OCCUPATION DETAILS

OCCUPATION TYPE *

SECTOR OF ACTIVITY *

AVERAGE MONTHLY INCOME (USD) *

NAME & ADDRESS OF EMPLOYER / BUSINESS *

VERIFICATION DOCUMENTS

National ID / Passport *

Drag & Drop or Click to Upload

Supported formats: JPG, PNG, PDF (Max 5MB)

Proof of Address *

Drag & Drop or Click to Upload

Supported formats: JPG, PNG, PDF (Max 5MB)

Location Verification (same as proof of address) *

VIDEO VERIFICATION *

Please record a video of yourself holding your ID document (Passport or National ID) and speaking your name and date of birth.

2. DIGITAL ASSETS SERVICES

OVERALL YEARLY EXPECTED TRANSACTIONS/ACTIVITY (EQUIVALENT USD) *

Note: For expected yearly transactions above $25,000, it is required to provide the supporting documents as mentioned in Annexure A.

2B. ASSET DETAILS *

What type of assets do you want to invest in ?

TYPE OF ASSET	INITIAL AMOUNT (USD)	SOURCE OF FUNDS	ACTION

3. SOURCE OF FUNDS & SOURCE OF WEALTH DECLARATION

This should be completed for Individual Client and Ultimate Beneficial Owner (UBO) / Shareholder / Settlor / Founder / Controlling Person (as applicable).

SOURCE OF FUNDS CONFIRMATION

I/We confirm that the funds and/or assets transferred or to be transferred to MINDEX are sourced from my/our personal assets and/or from benefits of transactions due to me/us of which are known to me/us as described below:

DESCRIPTION OF SOURCE OF FUND *

SOURCE OF WEALTH CONFIRMATION

I/We confirm that my accumulated wealth is derived from legitimate sources, which are not linked and/or derived from criminal origin, of whatsoever nature, and do not constitute the proceeds of money laundering or terrorist financing. The origins of my accumulated wealth are described as below:

DESCRIPTION OF SOURCE OF WEALTH *

DECLARATION OF SOURCE OF FUNDS & SOURCE OF WEALTH

Source of Funds (SoF): SoF refers to the origin of the funds used for specific transaction or business relationship.
Source of Wealth (SoW): SoW describes the economic activities leading to the total net worth.

I/We further confirm that any transfer of funds or assets to the MINDEX are not in breach of money laundering regulations and laws applicable to Mauritius including The Financial Intelligence and Anti-Money Laundering Act 2002, The Financial Intelligence and Anti-Money Laundering Regulations 2018, Financial Crimes Commission Act 2023 and The Prevention of Terrorism Act 2002.

DECLARATION NAME *

hereby declare that the information provided in this statement is true, complete, and accurate to the best of my knowledge. I understand that any false or misleading information may result in rejection of my application or future disqualification. By ticking the box below, I acknowledge this declaration and accept full responsibility for the information submitted.

I/We confirm that I have read and understood the above declaration and take full responsibility for the accuracy of the information provided.

4. DISCIPLINARY HISTORY AND RELATED MATTERS *

If a Client is uncertain about the materiality of a specific disciplinary proceeding or event, the matter should be disclosed in the comments box below.

IF ANSWERED 'YES' TO ANY OF THESE QUESTIONS, PLEASE PROVIDE DETAILS BELOW, ATTACHING RELEVANT DOCUMENTS, IF ANY

Required Documents *

NB: If you intend/ or in fact custody or exchange in excess of USD 100,000 worth of assets per year, please note that you will have to provide a Certified Copy of a Bank Reference (less than 3 months old) /6 months Bank Statement (less than 3 months). Failure to do so might result in your account being frozen until the said document is provided.

I/We confirm having read, understood and agreed to the Terms and Conditions, Fees Schedule, Listing Rules (as applicable) of MINDEX and the indemnity provision as disclosed on the MINDEX website.

Click here to view

I confirm that I have read, understood and agreed to the indemnity provision attached.

Click here to view

I confirm that the information provided above is accurate and true.