Document:

Exhibit 4.7

 

UNLESS THIS CERTIFICATE
IS PRESENTED BY AN AUTHORIZED REPRESENTATIVE OF THE DEPOSITARY (AS DEFINED
HEREIN) TO UBS AG OR ITS AGENT FOR REGISTRATION OF TRANSFER, EXCHANGE OR
PAYMENT, ANY TRANSFER, PLEDGE OR OTHER USE HEREOF FOR VALUE OR OTHERWISE BY OR
TO ANY PERSON IS WRONGFUL INASMUCH AS THE REGISTERED OWNER HEREOF, THE
DEPOSITARY, HAS AN INTEREST HEREIN.

 

TRANSFERS OF THIS GLOBAL
SECURITY SHALL BE LIMITED TO TRANSFERS IN WHOLE, BUT NOT IN PART, AND ONLY WITH
THE PRIOR WRITTEN CONSENT OF UBS AG.

 

AUCTION
RATE SECURITIES RIGHTS CERTIFICATE

 

UBS AG

 

Series G

 

              
Auction Rate Securities Rights

 

THIS CERTIFIES THAT                                             is the owner of                     
Auction Rate Securities Rights, Series G, or such greater or lesser number
as is indicated on Schedule I hereto.

 

THE AUCTION RATE
SECURITIES RIGHTS REPRESENTED BY THIS CERTIFICATE ARE BEING ISSUED PURSUANT TO
THE PROSPECTUS, DATED OCTOBER 7, 2008 (THE “PROSPECTUS”), OF UBS AG RELATING TO
THE SERIES OF AUCTION RATE SECURITIES RIGHTS IDENTIFIED ABOVE AND INCLUDED AS PART OF
THE REGISTRATION STATEMENT ON FORM F-3 OF UBS AG FILED WITH THE U.S. SECURITIES
AND EXCHANGE COMMISSION ON OCTOBER 7, 2008. THE PROSPECTUS CONTAINS A
DESCRIPTION OF THE SETTLEMENT PURSUANT TO WHICH THIS CERTIFICATE IS BEING
ISSUED. CAPITALIZED TERMS USED AND NOT OTHERWISE DEFINED HEREIN ARE USED AS
DEFINED IN THE PROSPECTUS.

 

Each ARS Right
represented by this Certificate entitles the beneficial owner thereof to sell
to UBS AG, at any time from October 31, 2008 to January 30, 2009 (or such later
date as UBS AG, in its discretion, may from time to time determine shall be the
expiration date of this Certificate), one share of ARS that is auction
preferred stock that is eligible pursuant to the terms of the Settlement (“Eligible
ARS”) for a price equal to the liquidation preference of each such Eligible ARS
plus accrued but unpaid dividends, if any. 
As consideration for the issuance of the ARS Rights, each beneficial
owner of an ARS Right has granted to UBS AG the discretion to purchase from
such beneficial owner, at any time from the business day following the date on
which each such beneficial owner opts into the Settlement to January 30, 2009
(or such later date or dates, as aforesaid), any or all of the Eligible ARS to
which such beneficial owner’s ARS Rights relate for a price equal to the
liquidation preference of each such Eligible ARS plus accrued but unpaid
dividends, if any.

 

 

This Certificate is registered
in the name of [UBS Securities LLC] [UBS Financial Services Inc.] (the “Depositary”)
on behalf of the beneficial owners of the ARS Rights represented hereby.  Ownership of beneficial interests in the ARS
Rights represented by this Certificate will be effected only through records
maintained at the Depositary.  This
Certificate will not be exchangeable for definitive ARS Rights registered in
the name of a beneficial owner of ARS Rights unless the Depositary is unwilling
or unable to continue to so act and a successor is not appointed by UBS AG
within 90 days or UBS AG elects to issue definitive ARS Rights.  Definitive ARS Rights of this series will be
issued in denominations of 1,000 ARS Rights and integral multiples
thereof.  If definitive ARS Rights are
issued, UBS AG will maintain in the Borough of Manhattan, New York City, one or
more offices or agencies where definitive ARS Rights may be presented for
performance and where replacement certificates representing ARS Rights may be
obtained for definitive ARS Rights that have been lost or mutilated.  Beneficial owners of ARS Rights will not be charged
a fee for any exchange of such definitive ARS Rights; provided,
however, that UBS AG may require payment
of a sum sufficient to cover any tax or other governmental charge payable in
connection therewith.

 

The ARS Rights
represented by this Certificate are contractual obligations of UBS AG and are
senior in right of payment to the ordinary shares, par value CHF0.10 per share,
of UBS AG.

 

This Certificate may be
transferred in whole and not in part and only with the prior written consent of
UBS AG.  The ARS Rights represented by
this Certificate may not be transferred, sold, assigned, pledged, hypothecated
or otherwise disposed of by the beneficial owner thereof.

 

This Certificate shall be
governed by and construed in accordance with the laws of the State of New York
(without giving effect to the principles thereof relating to conflicts of law
except Section 5-1401 of the New York General Obligations Law).

 

 

IN
WITNESS WHEREOF, UBS AG has caused this Certificate to be
executed by its duly authorized officers this         
day of               ,
2008.

 

 

	
   

  	
  UBS AG

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  
	
   

  	
   

  	
  Name:

  
	
   

  	
   

  	
  Title:

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  By:

  	
   

  
	
   

  	
   

  	
  Name:

  
	
   

  	
   

  	
  Title:

  

 

 

SCHEDULE
I

 

SCHEDULE OF
INCREASES OR DECREASES

 

The initial number of ARS
Rights, Series G represented by this Certificate is                      
rights.  The following increases or decreases
in the number of ARS Rights represented by this Certificate have been made:

 

	
  Date of Increase

  or Decrease

  	
   

  	
  Amount of

  Decrease in

  Number of ARS

  Rights

  	
   

  	
  Amount of

  Increase in

  Number of ARS

  Rights

  	
   

  	
  Number of ARS

  Rights Following

  Such Increase or

  Decrease

  	
   

  	
  Signature of

  Authorized

  OfficerExhibit 10.1

 

	
   

  	
  UBS Bank
  USA

  
	
  Variable
  Credit Line Account Number: (if applicable)

  
	
  5V

  	
   

  	
   

  
	
   

  	
  Fixed Credit
  Line Account Number: (if aaplicable)

  
	
  Credit
  Line Account Application and

  	
  5F

  	
   

  	
   

  
	
  Agreement
  for Individuals

  	
  SS# /
  TIN

  	
   

  
	
   

  	
  HA

  	
   

  	
  Internal Use Only

  
					

 

	
  For Internal Use Only

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Variable Credit Line
  Account at UBS Bank USA

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5V

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Fixed Credit Line
  Account at UBS Bank USA

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5F

  	
   

  	
   

  	
   

  	
   

  

 

	
  Collateral Account(s) at UBS
  Financial Services Inc.

  	
   

  	
   

  
	
  Insert the information
  below for each UBS Financial Services Inc. account to be pledged to secure
  the Borrower’s credit line.

  
	
  Full Collateral
  (Securities) Account Title

  	
  Branch

  	
  Account Number

  	
  FA#

  
	
  1)

  
	
  2)

  
	
  3)

  
	
  4)

  
	
  5)

  
	
  6)

  
						

 

	
  Credit Line Account

  
	
  Select the type of
  credit line account:

  	
   

  	
  Select the type of Credit
  Line Account:*

  
	
  o   Variable
  Credit Line Account

  	
   

  	
  o   Sole
  Borrower

  
	
  o   Fixed
  Credit Line Account

  	
   

  	
  o   Joint
  Borrowers

  
	
  o   Both

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  If you do not indicate your
  preference you will be deemed to

  	
  Please read carefully the Joint
  Credit Line Account Agreement

  
	
  have selected the “Both”
  option.

  	
   

  	
  section of the attached Credit
  Line Agreement.

  
	
   

  	
   

  	
   

  
	
  * Any person, whether married,
  unmarried or separated, may apply for separate credit.

  

 

	
  Borrower Information

  
	
  Complete this section
  for: a Sole Borrower Account or the Primary Borrower for Joint Borrowers.

  
	
   

  	
   

  	
   

  
	
  Basic Information

  	
   

  	
   

  
	
  First Name:

  	
   

  	
  Middle Name:

  	
   

  	
   

  	
  Location of
  Address:   

  	
  o  Home-Legal Residence 

  	
  o  Business-

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
        Primary

  
	
  Last Name:

  	
   

  	
   

  	
  o  Other 

  
	
   

  	
   

  	
   

  	
        (specify):

  	
   

  
	
  Country of Citizenship:

  	
   

  	
   

  	
  SS#:

  	
   

  	
   

  	
  Street Address: (If a P.O. Box, complete the Additional Address

  
	
  o   USA  o   Other (specify)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Information on page 4.)

  
	
   

  	
   

  	
   

  	
   

  
	
  Passport/CEDULA and
  Green Card#: (If non-U.S. and no SS# 

  	
   

  	
   

  	
    City:

  	
  State:

  	
  Zip:

  
	
  specified)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  /

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Passport/CEDULA Country
  of Issuance:

  	
   

  	
   

  	
  Residence Telephone
  Number:

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Borrower Financial Information.
  If you share
  assets with another person, please provide financial information (e.g. annual
  income, liquid assets, net worth) per individual.

  
	
  Annual Income:

  	
  Liquid Assets:

  	
   

  	
  Is
  the Borrower a control person of UBS AG or its subsidiaries or 

  
	
   

  	
   

  	
   

  	
   

  	
  affiliates?:*

  
	
  Net Worth (exclusive of
  residence):

  	
   

  	
  o   Yes     o   No    If
  yes, please specify company and %:

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
  %

  
	
   

  	
   

  	
   

  
	
  Do you derive a
  substantial amount of your income/wealth 

  	
   

  	
   

  
	
  (over 50%) from a
  country outside of the United States?

  	
   

  	
   

  
	
  o   No
      o   Yes        If
  yes, specify:

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Country(ies)

  	
   

  	
   

  
																								

 

	
  HA Rev 07/08 HA LOAD SPEDOC UX EHA V101

  	
   

  	
  Ó 2008 UBS Bank USA. All rights reserved.

  
	
   

  	
   

  	
  Sign and date the application on page 6

  

 

 

	
  

  	
  UBS Bank
  USA

  
	
  Variable
  Credit Line Account Number: (if applicable)

  
	
  5V

  	
   

  	
   

  
	
   

  	
  Fixed Credit
  Line Account Number: (if aaplicable)

  
	
   

  	
  5F

  	
   

  	
   

  
	
   

  	
  SS# / TIN

  	
   

  
	
   

  	
   

  	
   

  	
  Internal Use Only

  
					

 

	
  Borrower Personal Information

  	
   

  	
   

  
	
  Date of Birth:

  	
   

  	
  Is the Borrower an
  immediate family member of an executive officer or 

  
	
   

  	
   

  	
   

  	
  member of the board of
  directors of UBS AG? Immediate family member 

  
	
   

  	
   

  	
  means
  a spouse or any other relative residing in the Borrower’s 

  
	
  Does the Borrower own
  10% or more of the shares of any publicly traded company?

  	
   

  	
  household to whom the
  Borrower lends financial support.

  o    Yes       o      No
          If yes, please specify:

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  o     Yes         o     No    If
  yes, please specify company:

  	
   

  	
  Subsidiary
  or Affiliate

  	
  Employee
  Name and SS#

  
	
   

  	
   

  	
   

  
	
  Is the Borrower an
  officer or member of the board of directors of 

  	
   

  	
  Will any of the loan
  proceeds be used to repay any debt or obligation owed

  
	
  UBS AG, its subsidiaries
  or affiliates?

  	
   

  	
  to, or purchase an asset
  from, UBS AG or its subsidiaries or affiliates?

  
	
  o    Yes        o    No
          If yes, please specify:

  	
   

  	
  o    Yes       o     No
          If yes, please specify:

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Subsidiary or Affiliate

  	
   

  	
  Employee Name and SS#

  	
   

  	
  Subsidiary or Affiliate

  
	
   

  	
   

  	
   

  	
   

  
	
  * For purposes of these
  questions, “control” means a person or entity that either (a) owns, controls
  or has the power to vote 25% or more of any class of voting securities, (b)
  has the ability to control the election of the majority of the directors of a
  company, or (c) has the power to exercise a controlling influence over
  management policies.  A person or
  entity is presumed to have control of a company if the person or entity owns,
  controls or has the power to vote 10% or more of any class of voting
  securities of the company and (i) the person is an executive officer or
  director of the company or (ii) no other person has a greater percentage of
  that class of voting securities.

  
	
   

  	
   

  	
   

  
	
  Joint Borrowers

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Complete this section
  for the Additional Borrower in the case where there are
  Joint Borrowers.

  
	
   

  	
   

  	
   

  
	
  Basic Joint Borrower
  Information

  	
   

  	
   

  
	
  Joint Borrower First
  Name:

  	
  Middle Name:

  	
   

  	
  Location of
  Address    o   Home-Legal
  Residence  o    Business

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
  Primary

  
	
  Last Name:

  	
   

  	
   

  	
  o   Other (specify)

  	
   

  
	
   

  	
   

  	
  Street Address (If a P.O. Box, complete the Additional Address Information

  
	
  Country of Citizenship:

  	
  SS#:

  	
   

  	
  on page 4.):

  
	
  o    USA   o     Other
  (specify)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  City:

  	
  State:

  	
  Zip:

  
	
   

  	
   

  	
   

  
	
  Passport/CEDULA and
  Green Card#: (If non-U.S. and no SS# specified)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  /

  	
   

  	
   

  	
  Residence Telephone
  Number:

  
	
   

  	
   

  	
   

  	
   

  
	
  Passport/CEDULA Country of
  Issuance:

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Joint Borrower Financial
  Information. If
  you share assets with another person, please provide financial information
  (e.g. annual income, liquid assets, net worth) per individual.

  
	
  Annual Income:

  	
   

  	
  Liquid Assets:

  	
   

  	
  Is the Borrower a control
  person of UBS AG or its subsidiaries or affiliates?:*

  
	
   

  	
   

  	
   

  	
   

  	
  o   Yes   o   No      If
  yes, please specify company and %:

  
	
  Net Worth (exclusive of
  residence):

  	
   

  	
   

  	
   

  	
   

  	
  %

  
	
   

  	
   

  	
   

  
	
  Do you derive a
  substantial amount of your income/wealth (over 50%) from a country outside of
  the United States?

  	
   

  	
   

  
	
  o   No    o     Yes        If
  yes, specify:

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Country(ies)

  	
   

  	
   

  
	
  Joint Borrower Personal
  Information

  	
   

  	
   

  
	
  Date of Birth:

  	
   

  	
  Is the Borrower an
  immediate family member of an executive officer or 

  
	
   

  	
   

  	
   

  	
  member of the board of
  directors of UBS AG? Immediate family

  
	
   

  	
   

  	
  member means a spouse or
  any other relative residing in the Borrower’s 

  
	
  Does the Borrower own
  10% or more of the shares of any publicly 

  	
   

  	
  household to whom the
  Borrower lends financial support.

  
	
  traded company?:

  	
   

  	
  o   Yes      o    No     If
  yes, please specify:

  
	
  o     Yes   o      No
           If yes, please specify
  company:

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Subsidiary or Affiliate

  	
   

  	
  Employee Name and SS#

  
	
   

  	
   

  	
   

  	
   

  
	
  Is the Borrower an
  officer or member of the board of directors of UBS AG, it’s subsidiaries or
  affiliates?

  	
   

  	
  Will any of the loan
  proceeds be used to repay any debt or obligation owed to, or purchase an
  asset from, UBS AG or its subsidiaries or affiliates?

  
	
  o   Yes      o    No     If
  yes, please specify:

  	
   

  	
  o   Yes      o    No     If
  yes, please specify:

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Subsidiary or Affiliate 

  	
   

  	
  Employee Name and SS#

  	
   

  	
  Subsidiary or Affiliate

  
	
   

  	
   

  	
   

  
	
  * For purposes of these
  questions, “control” means a person or entity that either (a) owns, controls
  or has the power to vote 25% or more of any class of voting securities, (b)
  has the ability to control the election of the majority of the directors of a
  company, or (c) has the power to exercise a controlling influence over
  management policies.  A person or
  entity is presumed to have control of a company if the person or entity owns,
  controls or has the power to vote 10% or more of any class of voting
  securities of the company and (i) the person is an executive officer or
  director of the company or (ii) no other person has a greater percentage of
  that class of voting securities.

  
	
   

  	
   

  	
   

  
	
  HA Rev 07/08 HA LOAD
  SPEDOC UX E HA V101

  	
   

  	
  ©2008 UBS Bank
  USA. All rights reserved.

  
	
   

  	
   

  	
  Sign and date the
  application on page 6

  
																																			

 

2

 

	
   

  	
  UBS Bank
  USA

  
	
  Variable
  Credit Line Account Number: (if applicable)

  
	
  5V

  	
   

  	
   

  
	
   

  	
  Fixed Credit
  Line Account Number: (if aaplicable)

  
	
   

  	
  5F

  	
   

  	
   

  
	
   

  	
  SS# / TIN

  	
   

  
	
   

  	
   

  	
   

  	
  Internal Use Only

  
					

 

Joint Borrowers

Complete this section for the Additional Borrower in the case where there are Joint Borrowers.

 

Basic Joint Borrower Information

	
  Joint Borrower First
  Name:

  	
  Middle Name:

  	
  Location of Address

  	
  o   Home-Legal Residence

  	
  o   Business-Primary

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Last Name:

  	
   

  	
   

  	
  o   Other (specify)

  	
   

  
	
   

  	
   

  	
   

  	
  Street Address (If a P.O. Box, complete the Additional Address Information on page 

  4.):

  
	
   

  	
   

  	
   

  
	
  Country of Citizenship:

  	
   

  	
  SS#:

  	
   

  
	
  o   USA   o   Other (specify)

  	
   

  	
   

  	
   

  	
   

  	
    City:

  	
     State:

  	
  Zip:

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Passport/CEDULA and
  Green Card#: (If non-U.S. and no SS# specified)

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  /

  	
   

  	
   

  	
  Residence Telephone
  Number:

  	
   

  
	
  Passport/CEDULA Country
  of Issuance:

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
																	

 

Joint Borrower Financial Information. If you
share assets with another person, please provide financial information (e.g.
annual income, liquid assets, net worth) per individual.

 

	
  Annual Income:

  	
  Liquid Assets:

  	
  Is the Borrower a
  control person of UBS AG or its subsidiaries or affiliates?:*

  
	
   

  	
   

  	
   

  	
   

  	
  o   Yes      o   No    If yes, please specify company and %:

  
	
  Net Worth (exclusive of
  residence):

  	
   

  	
   

  	
   

  	
  %

  
	
   

  	
   

  	
   

  
	
  Do you derive a
  substantial amount of your income/wealth (over 50%) from

  a country outside of the United States?

  	
   

  
	
  o   No
       o   
  Yes    If yes, specify:

  	
   

  
	
   

  	
   

  	
   

  
	
  Country(ies)

  	
   

  
	
  Joint Borrower Personal
  Information

  	
   

  
	
  Date of Birth:

  	
   

  	
  Is the Borrower an
  immediate family member of an executive officer or member of the board of
  directors of UBS AG? Immediate family member means a spouse or any other
  relative residing in the Borrower's household to whom the Borrower lends financial
  support.

  
	
  Does the Borrower own
  10% or more of the shares of any publicly traded company?: 

  
	
  o  
  Yes     o   No   If yes, please specify company:

  	
  o    Yes
      o     No
        If yes, please specify:

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Subsidiary or Affiliate

  	
  Employee Name and SS#

  
	
  Is the Borrower an
  officer or member of the board of directors of UBS AG,

  it’s subsidiaries or affiliates?

  	
  Will any of the loan
  proceeds be used to repay any debt or obligation owed to, or purchase an
  asset from, UBS AG or its subsidiaries or affiliates?

  
	
  o  
  Yes     o   No   If yes, please specify:

  	
  o    Yes
      o     No
        If yes, please specify:

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Subsidiary or Affiliate

  	
  Employee Name and SS#

  	
  Subsidiary or Affiliate

  
	
   

  	
   

  	
   

  
	
  *For purposes of these
  questions, “control” means a person or entity that either (a) owns, controls or has the
  power to vote 25% or more of any class of voting securities, (b) has the
  ability to control the election of the majority of the directors of a
  company, or (c) has the power to exercise a controlling influence over
  management policies. A person or entity is presumed to have control of a
  company if the person or entity owns, controls or has the power to vote 10%
  or more of any class of voting securities of the company and (i) the person
  is an executive officer or director of the company or (ii) no other person
  has a greater percentage of that class of voting securities.

  
	
   

  	
   

  	
   

  
	
  Credit Line Account Features

  	
   

  	
   

  
	
  Check Writing

  	
   

  	
  Alternate Mailing Address for
  Checks

  
	
  If you would like to
  receive Credit Line checks for your credit line account, please enroll below:

  	
  Print the mailing
  address for the delivery of checks if different from the address on the
  checks:

  
	
   

  	
   

  
	
  o   Check here if you
  would like Credit Line checks.

  	
   

  
	
  Checks will be in the
  name of the borrower and joint borrower (if any). 

  	
   

  
	
  Please print the address
  that you would like to appear on your checks.

  	
   

  
	
   

  	
   

  	
  Wire Instructions for Loan
  Payment:  (In US Dollars)

  
	
   

  	
   

  	
  Bank Name: UBS AG

  
	
   

  	
   

  	
  Wire System Address: ABA 026007993

  
	
   

  	
   

  
	
   

  	
  For Further Credit to the
  Account of: UBS
  Bank USA

  
	
   

  	
  Account Number: 101-WA-792479-000

  
	
   

  	
   

  
	
   

  	
  For the Benefit of: Full Name

  
	
   

  	
  Account Number: 5[F or V] 00000

  
										

 

	
  HA Rev
  07/08 HA LOAD SPEDOC UX E HA V101

  	
  ©2008 UBS Bank USA. All rights reserved.

  
	
   

  	
  Sign
  and date the application on page 6

  

 

3

 

	
   

  	
  UBS Bank
  USA

  
	
  Variable
  Credit Line Account Number: (if applicable)

  
	
  5V

  	
   

  	
   

  
	
   

  	
  Fixed Credit
  Line Account Number: (if aaplicable)

  
	
   

  	
  5F

  	
   

  	
   

  
	
   

  	
  SS# / TIN

  	
   

  
	
   

  	
   

  	
   

  	
  Internal Use Only

  
					

 

Senior Political Affiliation

 

Are you, any authorized
signatories, beneficial owners, trustees, powers of attorney or other
individuals with authority to effect transactions, or any of their immediate family
members or close associates a:

 

	
  I)

  	
   

  	
  Current
  U.S. political official (as defined in section B below)?
               o No
        o Yes; complete:

  

 

	
   

  	
  A)
  Political Official’s Name:

  	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  B)
  Current Position:

  	
  o President

  	
  o Vice President 

  	
  o US Cabinet Member

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  o Speaker of the House
  of Representatives

  	
  o Supreme Court
  Justice

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  o Chairman of the
  Joint Chiefs of Staff

  	
  o Ambassador

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  C)
  Relationship to Client(s):

  	
  o Self 

  	
  o Immediate family
  member 

  	
  o Close associate

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  o Associates with business
  or trust

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  II) Current or former
  Senior non-U.S. political official, non-U.S. Religious Group/Organization, or
  Senior/Influential   o No o Yes; complete:
  representative of a non-U.S. Religious Group/Organization?

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Political
  Official’s Name:

  	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  Current
  or Former Position:

  	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  Relationship
  to Client(s): 

  	
  o Self 

  	
  o Immediate family
  member

  	
  o Close associate

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  o Associates with
  business or trust

  	
   

  
										

 

Duplicate
Party Addendum

 

Complete this section for each Duplicate Party to receive a duplicate
credit line account statement.

 

	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Internal Location Code (UBS Financial Services
  Inc. Use Only)

  
	
  Name:

  	
   

  	
  Country of Citizenship:

  
	
   

  	
   

  	
  o

  	
  USA

  	
  o

  	
  Other (specify):

  	
   

  
	
  Street Address:

  	
   

  	
  City:

  	
  State:

  	
   

  	
  Zip:

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Internal Location Code (UBS Financial Services
  Inc. Use Only)

  
	
  Name:

  	
   

  	
  Country of Citizenship:

  
	
   

  	
   

  	
  o

  	
  USA

  	
  o

  	
  Other (specify):

  	
   

  
	
  Street Address:

  	
   

  	
  City:

  	
  State:

  	
   

  	
  Zip:

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Additional Address Information

  If your mailing address is a P.O. Box please
  provide a residential street address below:

  
	
   

  	
   

  	
   

  
	
  First Name:

  	
   

  	
  Last Name:

  	
   

  	
  Street Address:

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Location of Address:

  	
   

  	
   

  	
   

  	
   

  
	
  o  Home - Legal Residence

  	
   

  	
  o  Business - Primary

  	
   

  	
   

  
	
  o  Home - Secondary

  	
   

  	
  o  Business - Secondary

  	
   

  	
  City:

  	
  State:

  	
   

  	
  ZIP:

  
	
  o  Other (specify) 

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
													

 

	
  HA Rev 07/08 HA LOAD SPEDOC UX E HA V101

  	
  ©2008 UBS Bank USA. All
  rights reserved.

  
	
   

  	
  Sign and date the
  application on page 6

  

 

4

 

	
   

  	
  UBS Bank
  USA

  
	
  Variable
  Credit Line Account Number: (if applicable)

  
	
  5V

  	
   

  	
   

  
	
   

  	
  Fixed Credit
  Line Account Number: (if aaplicable)

  
	
   

  	
  5F

  	
   

  	
   

  
	
   

  	
  SS# / TIN

  	
   

  
	
   

  	
   

  	
   

  	
  Internal Use Only

  
					

 

	
  First Name:

  	
   

  	
  Last Name:

  	
   

  	
  Street Address:

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Location of Address:

  	
   

  	
   

  	
   

  	
   

  
	
  o  Home - Legal Residence

  	
   

  	
  o  Business - Primary

  	
   

  	
   

  
	
  o  Home - Secondary

  	
   

  	
  o  Business - Secondary

  	
   

  	
  City:

  	
  State:

  	
   

  	
  ZIP:

  
	
  o  Other (specify):

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
									

 

	
  HA Rev 07/08 HA LOAD SPEDOC UX E HA V101

  	
  ©2008 UBS Bank USA. All
  rights reserved.

  
	
   

  	
  Sign and date the
  application on page 6

  

 

5

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00148-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00148-of-00352.parquet"}]]