FMDA-0629

AUTHORIZED SIGNATORY
08/06/2019
Per Board Resolution / Secretary’s Certificate Dated __________________
CUSTOMER INFORMATION
CORPORATE NAME DATE

SCIGEN-LEVANT INC. dd
SIGNATORY NAME(Last Name, First Name, Middle Name)

DOMENDEN, ADAM ALBERT ABOG

DATE OF BIRTH(MM/DD/YYYY) PLACE OF BIRTH GENDER

10/03/2021 MAKATI CITY MALE

PRESENT ADDRESS (House No./ Building Name/ Block and Lot No./ Street)

BLOCK 56 LOT 32 RAFAEL ST. VILLAGGIO IGNATIUS. BUENAVISTA 1, GENERAL TRIAS CITY, CAVITE 4017
CONTACT NO. E-MAIL ADDRESS NATIONALITY

09171520061 ADAMDOMENDEN@ICLOUD.COM FILIPINO

FATCA DETAILS (If US Citizen or Filipino with Dual Citizenship)

N/A
OVERSEAS ADDRESS

N/A
OVERSEAS TAX ID NO. OVERSEAS PHONE/ MOBILE NO.

N/A N/A
NATURE OF WORK POSITION

SELF-EMPLOYED PRESIDENT
SOURCE OF FUNDS* SOURCE OF WEALTH** VOLUME OF ASSETS

BUSINESS EMPLOYMENT AND BUSINESS

*Source of Fund refers to the origin of the funds or other monetary instrument that is the subject of the transaction, or business or professional relationship between a covered person and
its customer, such as cash on hand, safety deposit box with a covered person, and a particular bank or investment account.

**Source of Wealth refers to the resource from which the customer’s wealth, including all monetary instruments and properties, came, comes, or will come from, such as employment,
business, investment, foreign remittance, inheritance, donation, and winnings.