Name *

First Name

Last Name

Cell Phone *

Country

(###)

###

####

Registered Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is the applicant or any of its authorized controllers a politically exposed person ("PEP")? *

Yes

No

Has the applicant or any authorized individual been convicted of a crime? *

Yes

No

Has the applicant ever been sanctioned by any other financial regulator, Self-Regulatory Organization, National Competent Authority? *

Yes

No

All fiat digital asset transfer instructions will reflect account(s) or wallet(s) which are owned and controlled by the entity described in this application? *

Yes

No

I hereby confirm all of the information that I have provided is accurate and correct. *

Yes