Contact - Electronic Money Institution Licensing

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First Name *

Email Address *

Surname *

Phone number *

Street Address *

City *

State or Province *

Postal Code *

Country *

Skype

Web Site (if available)

Name of existing Company *

Date Company started doing business *

Physical location of the Company *

Are you a Regulated Entity (please name Regulator) *

The Business activities of the Company *

Current banking relationships *

Explanation of intended activity of the Financial Service Provider *

Countries prospective clients reside *

Additional information

How have you learned about us? *

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