Menara Kebon Sirih, 20-21th Floor Jakarta, 10340 INDONESIA Tel.

: +62 (21) 392-9929 Fax: +62 (21) 392-9927 Email: info@mdicorps.com

CUSTOMER INFORMATION SHEET Account No: Date Opened:

Account Name: Nationality: Date of Birth: Country of Residence: Home Address: Passport/I.D. No: Valid To: Profession/Occupation:

Mailing Address:

Tel:

Fax:

Mobile:

Customer Profile (Please tick the appropriate box) Annual Income: Approx. Net Worth: Do you own your own home: Trading Experience: Futures & Options Bonds & Shares Forex Bullion Commodities Banking Information: Bank Name: Bank Address: Below 1 Year Below 1 Year Below 1 Year Below 1 Year Below 1 Year 1-3 Years 1-3 Years 1-3 Years 1-3 Years 1-3 Years Above 3 Years Above 3 Years Above 3 Years Above 3 Years Above 3 Years Below $50,000 Below $50,000 $50,000 - $100,000 $50,000 - $100,000 Yes Above $100,000 Above $100,000 No

Sorting Code:

Account No:

Customer Information Sheet Millennium Penata Futures 2000-2005

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Menara Kebon Sirih, 20-21th Floor Jakarta, 10340 INDONESIA Tel.: +62 (21) 392-9929 Fax: +62 (21) 392-9927 Email: info@mdicorps.com

To: PT Millennium Penata Futures, I/We hereby confirm that the above information is true and factual to the best of my/our knowledge.

Name of Customer

Signature of Customer

_________________

_____________________

Name of Introduction Broker

Signature of Introduction Broker

_________________

_____________________

Customer Information Sheet Millennium Penata Futures 2000-2005

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