EFTA Document EFTA01387991

One sheet must be established for EACH INDIVIDUAL PARTY in Section 2. Account Ownership Summar 3A. Individual Details . 'a' , oc': es, ndividual's Name Date of Birth: Country of Residence Country of Citizenship' Address of primary residence- -4as C ert rescec c.aside of hisiber country of nationality for 5 years or more? Yes t No Profession, Occupation N A Tax ID: SSN Current Employer: N A Position/Title( Rank NSA Address of employer: N A Does the person work as senior exec