Nicol Token Purchase

Nicol Token Purchase

APPLICATION AND KYC FORM
Proposed Token Purchase Amount ($USD or $AUD)*
Please let us know your intended purchase amount.
Referral (if someone referred you, please tell us their name)
A. Identity Details
1. Name of the Applicant

First NameLast Name
2a. Gender

MaleFemaleNon BinaryOther
2b. Marital Status

SingleMarriedDefacto
2c. Date of Birth

MonthDayYear
Date
3. Nationality
4. Status

Resident IndividualNon ResidentForeign National
6. Proof of Identity

UIDPassportVoter IDDriving LicensePANOther
B. Address Details
1. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
2. Phone Number
Please enter a valid phone number.
3. Email*
You need to provide a way for us to contact you.
4. Proof of Address to be Provided by Applicant

PassportRation CardDriving LicenseVoter Identity CardRegistered Lease/Sale Agreement of ResidenceLatest Bank Account Statement/PassbookLatest Telephone BillLatest Electricity BillLatest Gas BillOther
5. Permanent Address of Resident Applicant If Different From B1 Above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
6. Proof of Address to be Provided by Applicant

PassportRation CardDriving LicenseVoter Identity CardRegistered Lease/Sale Agreement of ResidenceLatest Bank Account Statement/PassbookLatest Telephone BillLatest Electricity BillLatest Gas BillOther
C. File Upload

Please upload related photographs and documents.
Cancelof
D. Declaration
I hereby declare that the information provided in this form is accurate and complete. I confirm that any information is found incorrect and/or incomplete that leads a violation of regulations may initiate legal actions, and I accept that I am the responsible party for any and all charges, penalties and violations.
By submitting this application, I acknowledge that I have read and agree to the Nicol Token Sale Terms and Conditions (https://www.niccoglobal.com/nicol-token-sale-terms-and-conditions).*

I agree.
Name of the Applicant

First NameLast Name
Signature of the Applicant

Clear
Date Signed

MonthDayYear
Date
For Office Use Only
Originals verified and Self-Attested Document copies received
Name of the Authorized Signatory

First NameLast Name
Signature of the Authorized Signatory

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Nicol Token Purchase

A. Identity Details

B. Address Details

C. File Upload

D. Declaration

For Office Use Only