1)

Home Member State

2)

Host Member State in which e-money services are to be provided

3)

Name of the competent authority of the home Member State

4)

Date of receipt by the competent authority of the home Member State of the complete and accurate application from the e-money institution

DD/MM/YY

5)

Type of application

☐ First application

☐ Change to previous application

☐ Additional distributors

☐ Distributor deactivation

6)

Nature of the application (assessment of the competent authority of the home Member State)

☐ Right of establishment

☐ Freedom to provide services, based on the following circumstances:

…

…

…

7)

Name of the e-money institution

8)

Head office address of the e-money institution

9)

Unique identification number of the e-money institution in the format of the home Member State as specified in Annex I (where applicable)

10)

Legal Entity Identifier (LEI) of the e-money institution (where available)

11)

Home Member State authorisation number of the e-money institution (where applicable)

12)

Contact person within the e-money institution

13)

Email of the contact person within the e-money institution

14)

Telephone number of the contact person within the e-money institution

15)

Distributor details:

16)

Electronic money services to be provided by the distributor

☐ Distribution

☐ Redemption of electronic money

17)

Description of the internal control mechanisms that will be used by the e-money institution/distributor in order to comply with the obligations in relation to the prevention of money laundering and terrorist financing under Directive (EU) 2015/849.

18)

In case of outsourcing of operational functions of e-money services: