FORMULIR PEMBUKAAN REKENING ACCOUNT OPENING FORM
PT BOWSPRIT ASSET MANAGEMENT
NAMA NASABAH : _____________________________________ Client Name KODE NASABAH Client Code NO. CIF CIF Number
: _____________________________________
: _____________________________________
PT BOWSPRIT ASSET MANAGEMENT Berita Satu Plaza, Lantai 6 Jl. Jend. Gatot Subroto Kav. 35-36 Jakarta Selatan 12950 Indonesia
Telp. : +6221 52900360 Fax. : +6221 52900361 Email :
[email protected] Website : www.bowsprit-am.com
PT BOWSPRIT ASSET MANAGEMENT Sebelum mengisi, harap membaca Prospektus dan catatan di halaman berikutnya. Gunakan huruf cetak/ketik dan beri tanda (X) sesuai pilihan anda.
Please read the Prospectus and information provided in the next page. Use block letters and put on (X) on your selection. KHUSUS PERORANGAN FOR INDIVIDUAL DATA NASABAH / CLIENT DATA Nama (sesuai KTP/Paspor) : ________________________________________________________________________________________________________________________________________________________ Name (as stated in ID/Passport) Alamat (sesuai KTP/Paspor) : ________________________________________________________________________________________________________________________________________________________ Address (as stated in ID/Passport) ____________________________________________________________________________________________________ Kode Pos/Postal Code : ________________________________ Alamat (korespondensi) Correspondence Address
: ________________________________________________________________________________________________________________________________________________________
No. NPWP Tax ID number
: _________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________ Kode Pos/Postal Code : ________________________________
DATA PRIBADI / PERSONAL DATA Jenis Identitas : □ KTP/ID Card □ Paspor/Passport □ Lainnya/Others ________________________________________________________ Identity Type No. Identitas : ___________________________________________________________________________________ Tanggal Kadaluarsa/Expiry Date : _______________________________________ Identity Card Number Tanggal Kadaluarsa/Expiry Date : _______________________________________________________________________________________________________________________________________________ Kewarganegaraan/Nationality Tempat/Tanggal Lahir Place/Date of Birth Jenis Kelamin/Sex
: □ WNI/Indonesian
□ WNA/Foreign Sebutkan (Please Mention) ______________________________________________________________________________________
: ___________________________________________________________________________________________________________________________________________________________ : □ Laki-laki/Male
□ Perempuan/Female
No. Telepon Rumah/Home Phone No. : _______________________________________________________________________________________
No. Faks/Fax No. : _______________________________________
Alamat Email/E-mail
: ______________________________________________________________________________________________ Seluler/Mobile Phone No. : __________________________________
Agama/Religion
: □ Islam/Moslem
Pendidikan/Education
: □ SD/Elementary School
□ Katolik/Catholic
□ Kristen/Christian
□ SMP/Junior High School
□ Hindu/Hindu
□ Buddha/Buddhist
□ SMU/Senior High School
□ Akademi/Academic
□ Lainnya/Others __________________________________ □ S1/Bachelor
□ S2/Master Degree
□ S3/Doctor
Status Perkawinan : □ Belum Menikah/Single □ Menikah/Married □ Janda/Widow □ Duda/Widower Marital Status Jumlah Tanggungan : ________________________ Orang/People (anak + istri/children + wife) _________________________ Orang Lainnya/other people Number of Dependents Status Rumah/Status of Residence : □ Milik Sendiri/Self owned □ Sewa/Rent □ Milik Keluarga/Family owned □ Lainnya/Other, Please Mention ____________________________ Menempati sejak/Occupied since
: _____________________________ Tahun/Year
____________________________ Bulan/Month
Nama Ibu Kandung : ___________________________________________________________________________________________________________________________________________________________ Mother’s Maiden Name
DATA PEKERJAAN / EMPLOYMENT STATUS Pekerjaan/Occupation :
□ Wiraswasta/Entrepreneur □ TNI/POLRI/Military/Police
□ Profesional/Professional □ Pengajar/Teacher
□ Karyawan Swasta/Employee □ Pelajar/Mahasiswa/Student
□ PNS/Civil Servant □ Ibu Rumah Tangga/Housewife
□ BUMN/Employee in State owned companies □ Lainnya/Others________________________
Nama Perusahaan Name of Company
: ___________________________________________________________________________________________________________________________________________________________
Alamat Perusahaan Company Address
: ___________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________
Kode Pos/Postal Code : ____________________
No. Telepon/Telephone Number : _______________________________________________________________________________ No. Faks/Fax Number : ________________________________________________ Jabatan/Position : __________________________________________________________________________________________ Lama Bekerja/Years in Working : _______________________ Tahun/Year Bidang Usaha/Nature of Business : _________________________________________________________________________________________________________________________________________________
DATA KEUANGAN / FINANCIAL INFORMATION Tujuan Investasi : □ Apresiasi Harga/Price Appreciation □ Investasi/Investment □ Spekulasi/Speculation Investment Objectives Sumber Dana : □ Gaji □ Hasil Usaha □ Hasil Investasi □ Dari Orang Tua/Anak/Suami/Istri Source of Fund Salary Business Profit Investment Income From Parents/children/Spouse Penghasilan /Tahun Annual Income
: □ < Rp 10 juta < IDR 10 Million
□ Rp 10 juta – Rp 50 juta IDR 10 Million – IDR 50 Million
□ Pendapatan/Income □ Warisan Beneficiary
□ Hibah Grant
□ Lainnya/Others __________________________________ □ Undian Lottery
□ Lainnya _____________________ Others
□ Rp 50 juta – Rp 100 juta □ Rp 100 juta – Rp 500 juta □ Rp 500 juta – Rp 1 miliar IDR 50 Million – IDR 100 Million IDR 100 Million – IDR 500 Million IDR 500 Million – IDR 1 Billion
Dengan ini saya/kami menyatakan bahwa semua informasi/data yang diberikan adalah benar. I/We herewith state that all information that I/We have given in this Account Opening Form is correct. .
_________________, _________________
□ > Rp 1 miliar > IDR 1 Billion
DIISI OLEH PETUGAS/FILLED IN BY OFFICERS Marketing
Fund Admin
Direktur
Tanda Tangan/Signature
Tempat, Tanggal/Place, Date
Nama/Name Tanggal/Date
Tanda Tangan Nasabah/Signature
DATA AHLI WARIS / HEIRS DETAIL Nama/Name
: __________________________________________________________________
Alamat/Address : __________________________________________________________________
Nama/Name
__________________________________________________________________ Jenis Identitas Iidentity type
: □ KTP/ID Card □ Paspor/Passport □ Lainnya/Others __________________________
No. Identitas : __________________________________________________________________ ID Card Number Hubungan dengan Pewaris : __________________________________________________________ Relationship
: __________________________________________________________________________
Alamat/Address : _________________________________________________________________________ _________________________________________________________________________ Jenis Identitas Identity type
: □ KTP/ID Card □ Paspor/Passport □ Lainnya/Others ____________________________
No. Identitas : ________________________________________________________________________ ID Card Number Hubungan dengan Pewaris : ________________________________________________________________ Relationship
PT BOWSPRIT ASSET MANAGEMENT PROFIL INVESTASI / INVESTMENT PROFILE Tujuan investasi/Investment Objectives ① Likuiditas & keamanan investasi Liquidity & investment security
② Pendapatan & perlindungan terhadap inflasi Income & protection against inflation
③ Pendapatan & pertumbuhan dalam jangka pendek Income & short time growth
④ Pendapatan & pertumbuhan dalam jangka panjang Income & long time growth
Tingkat risiko yang sanggup ditanggung/Acceptable level of risk ① Risiko rendah Low risk
② Risiko rendah-menengah Low-medium risk
③ Risiko menengah Medium risk
④ Risiko tinggi High risk
Jangka waktu investasi/Investment period ① < 1 tahun < 1 year
② 1 - 3 tahun 1 – 3 year
③ 3 - 5 tahun 3 – 5 year
④ > 5 tahun > 5 year
Apa yang anda lakukan jika investasi anda mengalami kerugian > 25% dari modal What would you do if your investment value goes down > 25% from your initial investment ① Jual secepatnya untuk mencegah kerugian lebih jauh Sell as soon as possible to prevent further loss
② Tahan dulu & menjualnya ketika kembali modal Hold it & Sell it when break even
③ Bertahan dengan investasi ini untuk jangka panjang Hold it for long-term
④ Beli lebih banyak lagi agar menurunkan harga rata-rata pembelian Buy more in order to lower the average purchase price
Jumlah investasi yang ditanamkan dalam instrumen pasar modal dari total asset Amount of total asset invested in capital market instrument ① < 5%
② 5% - 10%
③ 10% - 20%
④ > 20%
Pengetahuan mengenai instrumen pasar modal Knowledge of capital market instruments ① Terbatas/Limited
② Cukup/Middle
③ Mampu/Capable
④ Ahli/Expert
Total poin Total point Profil risiko investasi Investment risk profile
6 - 12
13 - 18
19 - 24
Konservatif Conservative
Moderat Moderate
Agresif Aggressive
Dengan ini saya/kami menyatakan bahwa semua informasi/data yang diberikan adalah benar adanya sesuai dengan profil investasi saya/kami. Dalam hal di kemudian hari saya/kami memilih instrumen investasi berbeda dengan profil risiko investasi sebagaimana disebut diatas, saya/kami bertanggung jawab penuh dengan pilihan investasi saya/kami. I/we declare that all the information/data provided are true according to my investment profile/us . In the later case I/we choose different investment instruments with investment risk profile as mentioned above, I/we take full responsibility with my investment options/us. __________________________ , ______________________________ Tempat, Tanggal/Place, Date
Tanda Tangan / Signature
DIISI OLEH PETUGAS/FILLED IN BY OFFICERS Pemasaran (Marketing) Tanda Tangan/Signature
Nama/Name Tanggal/Tanggal
Fund Admin (Fund Admin)
Direktur (Director)
. PENTING / IMPORTANT Harap dibaca sebelum mengisi Formulir Pembukaan Rekening Please read before filling the Account Opening Form Saya/kami telah menerima, membaca dan menyetujui syarat-syarat dalam Prospektus Reksa Dana kelolaan PT Bowsprit Asset Management yang akan saya/kami investasikan. Saya/kami memiliki wewenang dan kemampuan hukum untuk membeli Unit Penyertaan Reksa Dana, memiliki cukup umur dan yakin bahwa setiap investasi yang saya/kami lakukan sesuai dengan kebutuhan investasi saya/kami. Adalah kewajiban saya/kami untuk membaca setiap Prospektus dari Reksa Dana kelolaan PT Bowsprit Asset Management yang akan saya/kami akan investasikan atau pertukarkan unitnya. I/we have received , read and agree to the terms and conditions as stated in the Prospectus Mutual Funds managed by PT Bowsprit Asset Management where I / we invest . I / we have the authority and legal capacity to purchase Units of the Fund, has sufficient age life and believes that every inves tment that I / we do in accordance with my/our investment needs. It is my/our duty to read each prospectus of the Mutual Funds managed by PT Bowsprit Asset Management where I/We will invest or redeem the units. Unit Penyertaan Reksa Dana ditawarkan dan dijual berdasarkan Prospektus, Informasi tertulis lainnya yang dikeluarkan oleh Manajer Investasi serta Kontrak Investasi Kolektif Reksa Dana antara PT Bowsprit Asset Management (“Manajer Investasi”) dan Bank Kustodian. Mutual Funds Unit are offered and sold based on the prospectus , other written information issued by the Investment Manager a nd the Collective Investment Contract between PT Bowsprit Asset Management ("Investment Manager") and the Custodian Bank. Unit Penyertaan dijual berdasarkan informasi yang tertera di Prospektus dan Informasi lainnya yang dikeluarkan oleh Manajer Investasi. Manajer Investasi tidak bertanggung jawab atas informasi dan representasi selain dari yang tercantum dalam Prospektus dan Informasi tertulis lainnya yang dikeluarkan oleh Manajer Investasi. Units are sold based on the information contained in the Prospectus and other information issued by the Investment Manager. The Investment Manager is not responsible for the information and representations other than those contained in the Prospectus and other written information issued by the Investment Manager. Manajer Investasi dapat menolak/menunda investasi nasabah apabila nasabah belum atau tidak dapat melengkapi formulir dan dokumentasi dan/atau sesuai dengan ketentuan prinsip mengenal nasabah. Investment Manager may refuse / postpone customer’s investment if the customer can not or do not complete the forms and documentation and / or in accordance with the provisions of Know Your Customer principle. Reksa Dana atau Manajer Investasi tidak bertanggung jawab atas setiap kerugian, gugatan, ongkos, atau biaya dalam menjalankan instruksi yang diberikan kepadanya oleh investor. Mutual Funds or Investment Manager shall not be liable for any losses , claims , costs , or expenses in carrying out the instructions given by investors. Setiap instruksi penarikan hanya dapat ditujukan ke rekening bank dengan nama pemilik yang sama dengan nama yang tercantum di formulir registrasi ini. Every withdrawals instruction can only be made to the bank account under the same name with the name listed in this registration form. Saya/kami memahami bahwa semua penjabaran wewenang dan pernyataan dalam formulir ini berlaku untuk setiap investasi yang saya/kami lakukan ke dalam Reksa Dana kelolaan PT Bowsprit Asset Management sampai saya/kami memberitahukan Manajer Investasi atas setiap adanya perubahan secara tertulis. I/we understand that all of the authority and statements in this form applies to any investment that I / we make to Mutual Funds managed by PT Bowsprit Asset Management until I / we notify the Investment Manager on any changes in writing. Saya/kami setuju bahwa demi keamanan/proteksi, Manajer Investasi dapat meminta pernyataan tertulis dari saya/kami sebelum bertindak atas instruksi yang diberikan. I/we agree that for safety / protection , the Investment Manager may request a written statement from me / us before acting based on the instructions given.
PT BOWSPRIT ASSET MANAGEMENT KARTU SPESIMEN / SPECIMEN CARD NamaNasabah Client’s Name No. Rekening Account No. Nama Bank Bank Name No. Rekening Bank Account Bank No. Atas Nama On behalf Jenis Rekening Account types Tanda Tangan Signature
_________________________________________________________________ __________________________________________________________________ __ ________________________________________________________________
No. Telp. _________________________________________________ Phone No. No. HP/Faks. _________________________________________________ Mobile/Fax No. Kepemilikan Ownership
□ Sendiri Personal
□ Perusahaan Company
________________________________________________________________ ________________________________________________________________ □ Tabungan Savings
□ Giro Giro
Syarat Tanda Tangan □ Satu Signature requirement One
□ Dua Two
□ __________________
□ Lainnya__________________________________ Others Tanda Tangan Signature
Nama Name Tanda Tangan Signature
_____________________________________________________
Nama Name Tanda Tangan Signature
_____________________________________________________
Nama Name Stempel Perusahaan Company Stamp
_____________________________________________________
Nama Name
_____________________________________________________
PT BOWSPRIT ASSET MANAGEMENT KARTU SPESIMEN / SPECIMEN CARD NamaNasabah Client’s Name No. Rekening Account No. Nama Bank Bank Name No. Rekening Bank Account Bank No. Atas Nama On behalf Jenis Rekening Account types Tanda Tangan Signature
_________________________________________________________________ __________________________________________________________________ __ ________________________________________________________________
No. Telp. _________________________________________________ Phone No. No. HP/Faks. _________________________________________________ Mobile/Fax No. Kepemilikan Ownership
□ Sendiri Personal
□ Perusahaan Company
________________________________________________________________ ________________________________________________________________ □ Tabungan Savings
□ Giro Giro
Syarat Tanda Tangan □ Satu Signature requirement One
□ Dua Two
□ __________________
□ Lainnya__________________________________ Others Tanda Tangan Signature
Nama Name Tanda Tangan Signature
_____________________________________________________
Nama Name Tanda Tangan Signature
_____________________________________________________
Nama Name Stempel Perusahaan Company Stamp
_____________________________________________________
Nama Name
_____________________________________________________
PT BOWSPRIT ASSET MANAGEMENT KELENGKAPAN DAN PENGEMBALIAN FORMULIR COMPLETE AND RETURN FORM Lengkapi Formulir Pembukaan Rekening Reksa Dana ini dengan : Complete this Account Opening form along with Jenis rekening / Types of Accounts
Kelengkapan dokumen / Document Needed Fotokopi KTP/identitas /Copy of ID Card/Identity Fotokopi NPWP / Copy of Tax ID Number Fotokopi bukti transfer / Copy of proof of transfer
Perorangan / Individual
PT/ Company
BUMN/ State-owned Companies
Yayasan/ Foundation
Dana Pensiun/ Pension Fund
Koperasi/ Co-operative
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Kembalikan formulir ini ke : Return this form to PT Bowsprit Asset Management Berita Satu Plaza, Lantai 6 Jl. Jend. Gatot Subroto Kav. 35-36 Jakarta Selatan 12950 Indonesia Telp. +6221 52900360 Fax. +6221 52900361
Kelengkapan dokumen / Document Needed Fotokopi akta pendirian dan perubahan terakhir berikut persetujuannya Copy of article of articulation and latest amendment and approval Ministry of Justice’s and Human Rights Republic Indonesia Fotokopi akta Notaris perihal susunan BOD dan BOC terbaru Copy of notarial deed concerning the composition of the latest BOD and BOC Fotokopi Akta Pendirian yg telah diumumkan dlm Berita Negara atau Tanda Daftar pada Kementrian Kehakiman (AD/ART+ perubahan terakhir) Copy of Deed of Establishment which was published within the Official Gazette or Certificate of Registration of the Ministry of Justice ( AD / ART + last amendment ) Fotokopi SIUP & TDP Copy of trading business licences & IndonesianCompany Registration Certificate Fotokopi SK Meneg BUMN (Pengganti SIUP) Copy of State-owned Companies Minister SK (Substitute licences) Fotokopi izin bidang kegiatan yayasan Copy license of foundation activities Gambaran kegiatan yayasan Description of activity the foundation Fotokopi Pengesahan Pendirian Dana Pensiun dari Menteri Keuangan RI Copy of Establishment of Pension fund endorsed of The Minister of Finance Buku peraturan Dana Pensiun Pension Fund regulation book Fotokopi surat keterangan domisili Copy of legal domicile Fotokopi NPWP Copy of Tax registration Fotokopi laporan keuangan ( 3 tahun terakhir ) Copy of latest Financial Statement Fotokopi KTP/identitas Pengurus/Direksi Copy of ID Card/management/Board of Directors Surat kuasa dari Pejabat yang ditunjuk (jika Authorized Signature diluar AD/ART) Original Power of attorney of the authorized officials (if authorized signature beyond AD/ART) Struktur kepemilikan dan manajemen terbaru Ownership structure and latest management Fotokopi bukti transfer Copy of proof of transfer
