Annex

APPLICATION FORM FOR AUTHORISATION AS A CRYPTO-ASSET SERVICE PROVIDER

1. In accordance with Article 2 and 4 of Commission Implementing Regulation (EU) 2025/306 of 31 October 2024 laying down implementing technical standards for the application of Regulation (EU) 2023/1114 with regard to standard forms, templates and procedures for the information to be included in the application for authorisation as a crypto-asset service providermeans a legal person or other undertaking whose occupation or business is the provision of one or more crypto-asset services to clients on a professional basis, and that is allowed to provide crypto-asset services in accordance with Article 59;(¹)OJ L, 2025/306, 31.3.2025, ELI: http://data.europa.eu/eli/reg_impl/2025/306/oj..

2. Reference number (to be completed by the competent authority): Date: FROM Name of the applicant: Address of the applicant / applicant’s registered office: Contact details of the designated contact person Name: Telephone: Email: TO Member State (if applicable): Competent authoritymeans one or more authorities:designated by each Member State in accordance with Article 93 concerning offerors, persons seeking admission to trading of crypto-assets other than asset-referenced tokens and e-money tokens, issuers of asset-referenced tokens, or crypto-asset service providers;designated by each Member State for the application of Directive 2009/110/EC concerning issuers of e-money tokens;: Address: Contact details of the designated contact point Name: Telephone: Email: We, [insert applicant’s name] declare that the submitted information is true, accurate, complete, up to date, and not misleading. If some information relates only to a future date, it is explicitly identified in the application and we undertake to notify the authority in writing without delay if any such information should turn out to be inaccurate, incomplete or misleading. Further, we undertake to inform the competent authoritymeans one or more authorities:designated by each Member State in accordance with Article 93 concerning offerors, persons seeking admission to trading of crypto-assets other than asset-referenced tokens and e-money tokens, issuers of asset-referenced tokens, or crypto-asset service providers;designated by each Member State for the application of Directive 2009/110/EC concerning issuers of e-money tokens; of any change concerning the information provided in this form. Person in charge of preparing the application Name: Status/position: Telephone: Email: Nature of the communication (tick the relevant box) ☐ Authorisation ☐ Notification of changes pursuant to Article 4(1) of Implementing Regulation (EU) 2025/306 (in case of notification of changes, only the relevant parts of the form which are amended should be filled) REQUIRED INFORMATION General information according to Article 1 of Commission Delegated Regulation (EU) 2025/305(2)Commission Delegated Regulation (EU) 2025/305 of 31 October 2024 supplementing Regulation (EU) 2023/1114 of the European Parliament and of the Council with regard to regulatory technical standards specifying the information to be included in an application for authorisation as a crypto-asset service provider (OJ L, 2025/305, 31.3.2025, ELI: http://data.europa.eu/eli/reg_del/2025/305/oj). … Programme of operations according to Article 2 of Delegated Regulation (EU) 2025/305 … Prudential requirements … Please insert the information referred to in Article 3 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Information about governance arrangements and internal control mechanisms … Please insert the information referred to in Article 4 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Business continuity … Please insert the information referred to in Article 5 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Detection and prevention of money laundering and terrorist financing … Please insert the information referred to in Article 6 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Identity and proof of good repute, knowledge, skills, and experience and of sufficient time commitment of the members of the management body … Please insert the information referred to in Article 7 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Information relating to shareholders or members with qualifying holdings … Please insert the information referred to in Article 8 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. ICT systems and related security arrangements … Please insert the information referred to in Article 9 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Segregation of clients’ crypto-assets and funds … Please insert the information referred to in Article 10 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Complaints-handling … Please insert the information referred to in Article 11 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Custody and administration policy … Please insert the information referred to in Article 12 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Operating rules of the trading platform and market abuse detection … Please insert the information referred to in Article 13 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Exchange of crypto-assets for funds or other crypto-assets … Please insert the information referred to in Article 14 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Execution policy … Please insert the information referred to in Article 15 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Provision of advice or portfolio management on crypto-assets … Please insert the information referred to in Article 16 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. Transfer services … Please insert the information referred to in Article 17 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application. [signature of legal representative]