ECOMMBANX - Fintech E-Account Platform

CLIENT FORM

Name of the Company*

Trading Name (if applicable)

Country of Registration*

Registered Address Note: not P.O.Box*

Correspondence Address*

Email Address*

Telephone number*

URL*

PART B: TYPE AND BUSINESS ACTIVITY

Where did you hear about us?

Type of Activity*

Issuing Authority

License number (if applicable)

Date of Issue

Expiration Date

PART C: CONTACT DETAILS

Name of the Director*

Email Address*

Telephone Number*

Name of the Authorised Representative*

Email Address*

Telephone number*

PART E: FINANCIAL INFORMATION

Expected value of Transactions (€)*

Years of operation in the industry*

Expected origin of the incoming funds*

Expected destination of the outgoing payments*

By using our Services and/or registering for an account with ECOMMBX, you are accepting the terms of this Privacy Notice and our User Agreement, and you are consenting to our collection, use, disclosure, retention and protection of your personal information. If you do not provide the information we require, we refrain the right not to provide our Services to you.

CLIENT FORM

PART A: CLIENT INFORMATION

PART B: TYPE AND BUSINESS ACTIVITY

PART C: CONTACT DETAILS

PART E: FINANCIAL INFORMATION

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