mandate by individual to open a non

AGENCE CA DIRECT
English Speaking Branch
6, bd du 122ème R.I.
12000 RODEZ - FRANCE
Tél. : 33.(0).565.75.75.33
Fax.: 33.(0).565.75.52.01
[email protected]
MANDATE BY AN INDIVIDUAL TO OPEN A NON-RESIDENT ACCOUNT IN FRANCE
Demande d’ouverture de DAV particulier non-résident en France
Type of Account
Individual
Joint
Type de DAV
Individuel
Joint
Account Holder (1)
Account Holder (2)
Titulaire
Co-titulaire
Last name / Nom
First names
_______________________________________
_______________________________________
Prénoms
_______________________________________
_______________________________________
Title / Titre
Fiscal Address of
Mr
Mrs
Miss
Mr
Mrs
Miss
M.
Mme
Mlle
M.
Mme
Mlle
Road / Rue __________________________________________________________________________
Account Holder (1) Town / Ville _________________________________________________________________________
Adresse fiscale du
titulaire
Postal Code
Telephone
Email Address
Code Postal _______________ Téléphone ___________________________ Email_________________________
Tenant
Owner
Other
Tenant
Since ________________________
Owner
Other
Since ________________________
Address in France
Road / Rue __________________________________________________________________________
Adresse en France
Town / Ville _________________________________________________________________________
Postal Code
Telephone
Code Postal ________________________________ Téléphone ___________________________________
Monthly Statements Would you like to receive your statements electronically or by post mail?
E-Statements
Relevé Mensuel
Paper Statements
Maiden Name
_______________________________________
_______________________________________
Nom de jeune fille
Date of birth
Day ________ Month _________ Year _________ Day ________ Month _________ Year _________
Date de naissance
Jour
Town
Ville
Country
Pays
Nationality
Nationalité
Mois
Année
Jour
Mois
Année
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Account Holder (1)
Account Holder (2)
Titulaire
Co-titulaire
Single
Married
Single
Married
Marital status
Célibataire
Marié(e)
Célibataire
Marié(e)
Situation matrimoniale
Widow(er)
Divorced
Widow(er)
Divorced
Veuf(ve)
Divorcé(e)
Veuf(ve)
Divorcé(e)
Nb. of dependants
Nb pers. à charge
Occupation
Profession
Employer
Employeur
Telephone
Téléphone
Since
Depuis
Annual Income
Since ____________________________
Since ____________________________
.................... Ages ...................................
.................... Ages ...................................
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
I declare that the answers I have given in this application form are to the best of my knowledge true and complete / je certifie
sur l’honneur l’exactitude des informations ci-dessus.
Date :
Account holder (1)
Account holder (2)
Titulaire
Co-titulaire
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Signature :
Name and Address of witness (Bank or Solicitor)
_____________________________________________________________________
Nom et adresse du témoin (Banque ou Notaire)
_____________________________________________________________________________________________________
Signature of witness:
Signature du témoin
___________________________________________________________________________________________________