Company Name: ___________________________________________________________________________________________

Company Number: _________________________

(the “Entity”)	Date (format: dd/mm/yyyy): ____/____/________

BVI Register of Members and Beneficial Ownership Information – Data Form

Please provide one form for each Shareholder, Beneficial Owner, Exempted Owner and Nominator

A-1. Basic Information - Individual

Given Name(s): ___________________________________________	Surname: ________________________________
Alias: ________________________________________________________________________________________________
Former Given Name(s): _____________________________________	Former Surname: ____________________________
Place of Birth: ________________________________________	Nationality: _______________________________________
Birth Date: ____/____/________	Gender: ☐ Male ☐ Female ☐ Other	Occupation: ____________________________

A-2. Basic Information - Legal Entity (“LE”)

Name: _______________________________________________________________________________________________
Company Number: _________________	Place of Incorp.: __________________	Date of Incorp.: ____/____/________
☐ The address provided in Section B is the Principal Address.
A-2a. Exempted Owner (Complete this section and section D. Ownership and Control if the LE is an Exempted Owner)
☐ Trustee under BVI Bank and Trust Companies Act
☐ Listed Company	Stock Exchange Name: ___________________________________________________________________
Ticker Symbol: _________________________________________	Listing Date: ____/____/________
Stock Exchange Regulator: ______________________________	Country: ______________________
☐ BVI Fund	License Number: ________________________________________________________________________
☐ Foreign Fund (Please provide a copy of license)	Fund Type (select one): ☐ Approved Fund ☐ Incubator Fund ☐ Private Fund ☐ Private Investment Fund ☐ Professional Fund ☐ Public Fund
☐ The Foreign Fund a Segregated Portfolio Company (SPC)
Disclosure and Transparency Rules: __________________________________________________
International Standards: ____________________________________________________________

B. Address (In case of Beneficial Owner, enter residential address. For LE, enter Registered Office or Principal Address.)

Line 1: ________________________________________________________________________________________________________
Line 2: ________________________________________________________________________________________________________
City, State and Zip Code: ____________________________________________	Country: _______________________________

C. Shareholding (Complete this section if the individual or LE is a shareholder)

Date Entered as Member: ____/____/________	Date Ceased as Member: ____/____/________
Number of Shares Held: _________________	Share Certificate Number, if applicable: _________
Class of Shares: Ordinary	Series, if appliable: ___________	☐ No Voting Rights
☐ This Individual or LE is acting as a Nominee Shareholder (Please complete a separate form for each Nominator)

C-1. Mortgage and Charge (Complete this section if the shares are mortgaged or charged)

Name of Mortgagee or Chargee: _________________________________________________________________________
Type: ☐ Mortgage ☐ Charge	Date Entered: ____/____/________	Date Discharged: ____/____/________
Statement: ____________________________________________________________________________________________

C-2. Nominator (Complete this section if another shareholder is acting as a Nominee Shareholder)

Name of Nominee Shareholder: _________________________________________________________________________
Date entered as Nominator: ____/____/________	Date Ceased as Nominator: ____/____/________

C-3. Joint Shareholding (Complete a separate form for each joint shareholder)

If shares are held jointly, select the type of joint holding: ☐ Joint Ownership ☐ Tenants in Common
Names of Joint Shareholders: ___________________________________________________________________________

D. Ownership and Control (Complete this section if the individual is a Beneficial Owner or the LE is an Exempted Owner)

Effective Date: ____/____/________	Cessation Date: ____/____/________
Ownership (direct or indirect):
☐ Share Percentage (min 10%): _______ %; Voting Rights Percentage, if different from shares (min 10%): _______ %
Control:
☐ Power to appoint or remove: (tick as appropriate) ☐ senior management ☐ directors ☐ partners
☐ Power to direct or veto: (tick as appropriate) ☐ investment decisions ☐ profit share ☐ capital returns of assets
☐ Control through debt instrument	☐ Power to direct amendments to constitutional documents
☐ Senior Management Official	☐ Other, please specify: __________________________________________________