For the Panamenian Corporation / Foundation request, please complete the folowing form.

JURISDICTION:
Panama Corporation
Belice Corporation
Costa Rica Corporation
BVI Corporation
Other. Specify:
 
CORPORATE NAME OPTIONS (please provide at least 3 options):

Panama Corporations may end in: Inc., Corp, or S.A. or their long versions
Belize and BVI Corporations may end in: Inc. Corp, S.A. or Ltd or their long versions

1.-
2.-
3.-
 
BOARD OF DIRECTORS:
If you’re going to request nominee directors please leave the spaces blank.  If you’re going to provide your directors please complete all the information requested and attach a scanned image or a clear photocopy of their passports or other official photo ID. For Belize and BVI corporations you may only use a single director.
President/Director:
Name:
Address:
City / State:
Country: Phone:
E-mail: Mobile:
Secretary/Director:
Name:
Address:
City/State:
Country: Phone:
E-mail: Mobile:
Treasurer/Director:
Name:
Address:
City/State:
Country: Phone:
E-mail: Mobile:
 
BENEFICIAL OWNERS:
Provide a clear scanned image or a clear photocopy of their passports or another official photo ID.  If there are more than one (1) beneficial owner please fill an extra beneficial owners declaration form.
Select Share Type:
 
Beneficial Owner 1:
Name:
Country of Citizenship: Passport or ID No.:
Place of birth: Date of birth:
Day
Month
Year
Current Residence Address: Date Since:
Street: Ap/House N°:
City: State / Province :
Country: Zip/Postal
Code:
Residence Telephone: Mobile:
Business Telephone: Fax:
Email: Indique proporción % de acciones:
 
My business occupation for the past three (3) years has been: (Give details: Company, Nature of Business, Position held, Period, etc.)
 
Beneficial Owner 2:
Name:
Country of Citizenship: Passport or ID No.:
Place of birth: Date of birth:
Day
Month
Year
Current Residence Address: Date Since::
Street: Ap/House N°:
City: State / Province :
Country: Zip/Postal
Code:
Residence Telephone: Mobile:
Business Telephone: Fax:
Email: Indique proporción % de acciones:
 
My business occupation for the past three (3) years has been: (Give details: Company, Nature of Business, Position held, Period, etc.)
 
Other questions
The intended activity of your IBC is:
Country/Countries where activity is to be undertaken:
Would you like to open a bank account in Panama for this company?
Yes
No

None of my or the company’s assets, net worth, income or activities relate in any manner to illegal armaments, money laundering, illegal drugs or other illegal controlled substance, or any activity that I know to be illegal in my country of citizenship, residence or domicile, and/or in the place of incorporation.

I do not intend to hinder, delay or defraud any creditors, or engage in any illegal conduct in relation to creditors and do not intend to engage the services of GLOSCORP in order to facilitate or otherwise engage in such activity.

I hereby expressly, specifically and unqualifiedly agree to wholly hold harmless and indemnify GLOSCORP, its shareholders, officers, directors, employees, agents and nominee shareholders and (or) nominee directors provided by GLOSCORP or its agents if any, from any liabilities of any kind or character arising out of any lawful actions taken by them in reliance upon any fact of statement contained in this declaration which may hereafter prove to be untrue or materially inaccurate.

 
Solicitor:
Name: Date of the request:
Day
Month
Year
E-mail:    
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