Please complete the following form using English alphabet characters only.

1. Account Details

*Please select base currency
*Please select Account Type

2. Personal Details

*Please enter valid First Name
*Please enter valid Last Name
*Please enter valid Father's Name
*Please enter valid Mother's Name
*Please enter valid Indentity Card/Passport Number
*Please select expiry date
*Please select Issuance Country
*Please select Nationality
*Please select date of birth
*Please select country of birth
*Please select tax country
*Please enter valid Marital Status
*Please enter valid Tax Identification Number
*Please select an option
*Please select an option
*Please select an option
*Please select an option
*Please enter valid Occupation/Profession
*Please enter valid Name of Employer
*Please enter valid Employment Address
*Please enter valid Employer's Line of Business
*Please select an option
*Please select an option
*Please enter valid What is your annual Fixed Income?
*Please enter valid Other Income
*Please select an option
*Please select an option
*Please enter valid In EUR
*Please enter valid In USD
Country Name of Sender Name of Sending Bank
1 *Required *Required *Required
2 *Required *Required *Required
3 *Required *Required *Required
Country Name of Beneficiary Name of Beneficiary Bank
1 *Required *Required *Required
2 *Required *Required *Required
3 *Required *Required *Required

3. Residential Address

*Please enter a valid Street
*Please enter a valid Town
*Please enter a valid Town
*Please select Country

4. Contact Details

*Please enter a valid Phone number
*Please enter a valid phone number
*Please enter a valid Phone number
*Please enter a valid email
*Please enter a valid Fax number

5. Self Certification


Tax Regulations require us to collect certain information about each investor’s tax residency and tax classifications. Tax Regulations as a term, refers to regulations created to enable automatic exchange of information and include Foreign Account Tax Compliance Act (FATCA).
In certain circumstances (including if we do not receive a valid self-certification from you) we may be obliged to share information on your account(s) with the relevant tax authorities.

Neither this form nor any related written or oral statements of FIDUS Investments Cyprus Ltd or any of its employees can be considered as tax advice. FIDUS recommends that clients consult a qualified tax adviser in order to determine their appropriate FATCA Status.

Notification: If YES to the above, please provide with a copy of the US Passport *Please select an option
Clarification: Once activated, a U.S. Green Card remains active for U.S. tax purposes (even if the holder resides outside the U.S. and even if the Green Card itself expires) until either: (1) it is voluntarily returned to the U.S. immigration authorities; or (2) it is administratively or judicially revoked by U.S. immigration authorities or a U.S. federal court. *Please select an option
Country TIN (Tax Identification Number)
1 *Required *Required
2 *Required *Required
3 *Required *Required
For further definitions please consult the IRS website: *Please select an option
  1. I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete.
  2. I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect or incomplete.
  3. I authorise the recipient of this form to provide, directly or indirectly, to any relevant tax authority or any party authorised to conduct an audit or other similar review of the recipient for tax purposes.
  4. I acknowledge and agree that information contained on this form may be reported to any relevant tax authority.
If you declare that you are a "Specified U.S. Person" you should provide a complete W-9 IRS Form *Please select an option

*Please accept the statement
*Please accept the Client Declaration
*Please accept the statement
*Please accept Terms and Conditions


By typing my signature and clicking register I confirm that:
  1. All confirmation and/or documentation provided by me during the account application process is accurate complete and up to date and that I intend to rely upon it
  2. I have read and understood all the information provided to me by Fidus Investments Cyprus Limited
  3. I consent and agree to the terms of all the above agreements and disclosure provided to me during the account application process
  4. I understand and agree that my electronic signature is the legal equivalent of a manual written signature.
*Please complete the challenge