Become a Member

1. General information:

Company name:

Company type:Partnership, Private limited liability company, Other (Please specify)

Date of incorporation:

Registration number:

Place of incorporation:

Tax ID:

Country of tax residency:(in which country does the company pay taxes)

2. Address details:

2.1. Registered address (as appears in the incorporation forms of the company)

Street address:

City/ Town:

State (if applicable):

Country:

Postal/ZIP code (if applicable):

2.2. Business address (The physical location of the company)

Street address:

City/Town:

State (if applicable):

Country:

Postal/ZIP code (if applicable):

2.3. Correspondence address (If correspondence address is different than registered or business address, please advise the difference):

Street address:

City/Town:

State (if applicable):

Country:

Postal/ZIP code (if applicable):

3. Contact details:

Main contact person (This is the person we will contact for any inquiry):

First name:

Middle name:

Last name:

Position:

Email

Mobile number

Landline Phone number:

4. Business activity:

Business industry:

Websites:

Business active since:

Trading/Brand name (s):

Number of direct employees: (Employed directly by the company)

Number of indirect employees:(Outsourced by other group companies)

Please provide detailed business description:

Describe your clients and how you target them:

Describe your suppliers:

Describe your main business partners:

List your products and (or) services:

Is the company part of a group structure:(if yes please provide the full group structure including all intra-group companies)

5. Licence(s) (Please provide information about any gaming related licences, permits or registrations held by the Company)

Licence Type

Issued by

Licence Number

Issue date

6. Financial indicators of the client:

Last calendar year’s turnover (in EUR):

Planned turnover for this calendar year (in EUR):

Planned turnover next calendar year (in EUR):

7. Bank details

Bank name:

Account Number:

IBAN:

SWIFT/BIC:

Account currencies:

8. Directors/legal representatives (Please use separate sheet if needed):

Director 1

Full name:

Full Home Address:

Place and date of birth:

Personal identification number:

Type of document (ID or Passport) and number of the document:

Issuing Country of the document:

Nationality:

Is the person politically exposed person? (PEP)

Director 2

Full name:

Full Home Address:

Place and date of birth:

Personal identification number:

Type of document (ID or Passport) and number of the document:

Issuing Country of the document:

Nationality:

Is the person politically exposed person? (PEP)

9. Ultimate Beneficiary Owners, for every UBO with 25% share, or more (Please use separate sheet if needed):

Beneficial Owner 1

Full name:

Full Home Address:

Place and date of birth:

Personal identification number:

Type of document (ID or Passport) and number of the document:

Issuing Country of the document:

Nationality:

Is the person politically exposed person? (PEP)

Beneficial Owner 2

Full name:

Full Home Address:

Place and date of birth:

Personal identification number:

Type of document (ID or Passport) and number of the document:

Issuing Country of the document:

Nationality:

Is the person politically exposed person? (PEP)

Authorized Signatory:

Print Name:

Position:

Date of signature:

MEMBERSHIP ADMISSION QUESTIONNAIRE

2.1. Registered address (as appears in the incorporation forms of the company)

2.2. Business address (The physical location of the company)

2.3. Correspondence address (If correspondence address is different than registered or business address, please advise the difference):

Main contact person (This is the person we will contact for any inquiry):

Director 1

Director 2

Beneficial Owner 1

Beneficial Owner 2

DECLARATION:

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