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Supplier/Customer Information Form
We kindly ask you to fill out the following form, duly signed and along
with the supporting documents. If you have any question concerning this form, do not
hesitate to contact us.
General Information
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Contact Details
Accounts Contact Details
Corporate Registry Information
Bank Information
Trade References
Reference 1
Reference 2
Any subsidiary companies belonging to your company
Subsidiary 1
Subsidiary 2
Checklist conflicting minerals (
www.conflictfreesourcing.org)
Please declare whether you are selling or entering any Conflict Minerals in your processes according the United States Dodd Frank Act (Section 1502) originating from the Following Countries: Democratic Republic of the Congo and its adjoining countries (Angola, Burundi, Central African Republic, Republic of the Congo, Rwanda, South Sudan, Tanzania, Uganda and Zambia as well as Kenya, Mozambique and South Africa)
If yes, kindly confirm that you have due diligence measures in place for supply chain transparency
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Do you have a responsible sourcing policy?
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If yes, please add along with this doc
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Click to choose a file or drag here
Confirmation of Validity
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I declare to have filled out this form to the best of my knowledge and confirm for its validity.
Signature
Please include the following documents along with this application:
Company Incorporation Certificate/ Articles of Organization/ Extract of
commercial register
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Click to choose a file or drag here
Bank proof of indicated bank account
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Click to choose a file or drag here
Company VAT Certificate
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Click to choose a file or drag here
Register
