开户申请表

1.客户信息

客户姓名（名字与姓氏）:

曾否更改姓名:

是

否

(如是，请附上证明文件: ……….…...…)

出生日期（日/月/年）:

国籍:

国民身份证/护照号码:

签发机关:

到期日:

现居地址:

户籍/常住地址:

联系电话:

电子邮件:

职业/职位:

工作单位名称:

所属行业类型:

单位地址:

单位电话:

在职时长:

2. 教育背景

教育程度:

硕士

学士

学士以下

技能培训:

客户在数字资产交易、数字资产衍生品、数字钱包管理方面的知识:

曾参加相关培训课程

有相关从业经验

有证券交易经验

无任何金融工具交易经验

3. 投资经验

是否曾在其他金融市场有投资经验:

是

否

市场名称:

产品类型:

国家:

投资年份 :

市场名称:

产品类型:

国家:

投资年份 :

4.合格投资者

客户是否为合格投资者？

否

是（如是，请说明）:

客户拥有不低于 10 亿瑞尔（约合 250,000 美元）的净资产；或

客户年收入不少于 8,000 万瑞尔（约合 20,000 美元）；或

客户曾在柬埔寨王国证券市场投资不少于 1 亿瑞尔（约合 25,000 美元）

5. 关联人（请附上身份证或护照复印件）

授权人:

否

是（请注明姓名）

授权人与账户持有人关系：

实益拥有人:

账户本人

他人（请注明姓名）

实控人:

账户本人

他人（请注明姓名）

6. 近三年是否涉及洗钱记录

否

是(如是，请说明)

7.补仓通知联系方式（Margin Call）

电话:

短讯:

传真:

邮件:

其他:

8. 附加开户申请资料

国民身份证复印件

户口簿

护照（外国人适用）

其他

9. 紧急联系人

姓名（名字与姓氏）:

关系:

地址 :

电话:

邮箱:

10. 公司意见（内部填写）

本人确认上述所提供的信息真实、准确。如有虚假或误导性陈述，愿承担法律责任。本人已知悉并理解柬埔寨证券交易监管局（SERC）及中央对手方公司的相关法律法规。本人同意遵守所有与衍生品交易相关的法律规定，亦同意公司在需要时向 SERC、中央对手方公司及主管机关披露与监控本人的相关信息。

首席执行官签名

日期:

客户签名

日期:

Account Opening Application Form

1. Customer Information

Customer Name (First and Last name):

Has the name been changed before:

Yes

(If yes, please attach supporting documents: ……….…...…)

Day/ Month/ year of birth:

Nationality:

National ID Card/ Passport Number:

Issued by:

Expiry date:

Current Address:

Permanent Address:

Personal Contact Phone number:

Email:

Occupation/ Role:

Workplace name:

Type of Business:

Workplace Address:

Workplace Phone Number:

Duration Serve:

2. Education Background

Education Level:

Master

Bachelor Degree

Lower than Bachelor

Skills:

Customer knowledge related with Digital Asset Trading, Digital Asset Derivatives, Digital Asset Wallet Management:

The customer attended a training course related to the product

The customer has/is currently experiencing work related to the production

The customer has/ is trading in securities

The customer has no experience trading in financial instruments

3. Investment experience

Experience trading in other financial markets:

Yes

Name of Marke:

Type of Product:

Country:

Year of investment:

Name of Marke:

Type of Product:

Country:

Year of investment:

4. Qualified Investors

Is the customer a qualified investor?

Yes

(if yes, please specify)

The customer has total net assets of at least 1,000,000,000 (one billion) r riels (Approximately USD 250,000) or

The customer has an annual income of at least 80,000,000 (eighty million) riels (Approximately USD 20,000)or

The customer has invested participation in the securities sector in the Kingdom of Cambodia of at least 100,000,000 (one hundred million) riels (Approximately USD 25,000).

5. Related Person (Please attach a copy of the identify card, passport of the related person)

Authorized person:

Yes(if yes, please specify)

Relationship between authorized person and account owner:

Beneficial Owner:

Persona

Other Person(if yes, please specify)

Controlling Person:

Persona

Other Person(if yes, please specify)

6. Money Laundering Record in the last 3 years

Yes(if yes, please specify)

7. Means of communication in case of a margin call

Phone Number:

Send a message:

Fax:

Email:

Other:

8. Attached documents for account opening request

Copy of National ID Card

Family Book

Passport (For foreigners)

Other

9. Person who can contacted in case of need

Name (First and Last name):

Relationship:

Address:

Phone Number:

Email:

10. Company Opinion

I hereby certify that the information I have provided above is true and correct. I undertake to be held legally responsible if any information provided is false or misleading. By signing this application, I understand the relevant laws and regulations of the Securities and Exchange Regulator of Cambodia (SERC) and Central Counterparty Companies. I agree to comply with the laws and regulations relating to derivative trading and consent to the Company monitoring and disclosing my information to the SERC, Central Counterparty Companies and competent authorities.

Signature of CEO

Date:

Customer’s Signature

Date:

ទម្រង់ពាក្យសុំបើកគណនី

១. ព័ត៌មានអតិថិជន
ឈ្មោះ(គោត្តនាមនិងនាម)៖……………………………………………….……………………………...…... ថ្ងៃខែឆ្នាំកំណើត៖ ………………………………... សញ្ជាតិ៖ …………………………………………..……... លេខអត្តសញ្ញាណបណ្ណ/លិខិតឆ្លងដែន/បណ្ណបើកបរ៖ …….……………ថ្ងៃចេញ៖ …………..………………. ថ្ងៃផុតកំណត់៖ …………………………………………………………………………………………....…… អាសយដ្ឋានបច្ចុប្បន្ន៖ …………………………………………………………………………………….….... លេខទូរសព្ទទំនាក់ទំនងផ្ទាល់ខ្លួន៖……………..…………………. អ៊ីម៉ែល៖ ……………………………...….. មុខរបរ/តួនាទី៖ ……………………….…………………………………………………………….……..…... ប្រាក់ចំណូលប្រចាំខែ៖…………………………………………………………………………………….……
២. អ្នកវិនិយោគិនគុណវុឌ្ឃិ
តើអតិថិជនជាវិនិយោគិនគុណវុឌ្ឃិដែរឬទេ? មិនមែន មែន (បើមែន សូមបញ្ជាក់) អតិថិជនមានទ្រព្យសកម្មសុទ្ធយ៉ាងតិច ១.000.000.០០០ រៀល (២៥០.០០០ ដុល្លារអាមេរិក) ឬ អតិថិជនមានចំណូលប្រចាំឆ្នាំយ៉ាងតិច ៨០.០០០.០០០ រៀល (២០.០០០ ដុល្លារអាមេរិក) ឬ អតិថិជនធ្លាប់បានចូលរួមវិនិយោគក្នុងវិស័យមូលបត្រនៅព្រះរាជាណាចក្រកម្ពុជាយ៉ាងតិច ១០០.០០០.០០០ រៀល (២៥.០០០ ដុល្លារអាមេរិក)
ខ្ញុំសូមធានាថាព័ត៌មានដែលខ្ញុំបានផ្តល់ជូនខាងលើ គឺជាព័ត៌មានដែលពិតប្រាកដ និងត្រឹមត្រូវទាំងស្រុង។ ខ្ញុំសូមសន្យាថានឹងទទួលខុសត្រូវចំពោះមុខច្បាប់ ប្រសិនបើព័ត៌មានណាមួយដែលផ្តល់ជូន ជាព័ត៌មានមិនពិត ឬនាំឱ្យយល់ខុស។ នៅពេលចុះហត្ថលេខានៅលើពាក្យស្នើសុំនេះ ខ្ញុំបានយល់ដឹងពីច្បាប់ និងបទប្បញ្ញត្តិពាក់ព័ន្ធរបស់ ក្រុមហ៊ុន និងនិយ័តករមូលបត្រកម្ពុជា។ ខ្ញុំយល់ព្រមអនុវត្តច្បាប់ និងបទប្បញ្ញត្តិដែលទាក់ទងនឹងការជួញដូរទ្រព្យ ឌីជីថលឱ្យបានខ្ជាប់ខ្ជួន និងយល់ព្រមឱ្យក្រុមហ៊ុនត្រួតពិនិត្យ និងបង្ហាញព័ត៌មានរបស់ខ្ញុំទៅនិយ័តករមូលបត្រ កម្ពុជា និងអាជ្ញាធរមានសមត្ថកិច្ច។

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