Digital Assets - Self Evaluation Form

Digital Assets - Self-Evaluation Form
Instruction

Please complete all sections of the form. Do not exceed more than 150 words for each field. Where the space allocated is insufficient, you may provide further information via additional exhibits and documents (e.g., white paper). For any additional attachments, please make clear reference to which section and question they are relevant to and upload them via the "File Upload" section at the end of this application.

In addition, the following documents are to be attached in conjunction with this form (if applicable):
- A copy of the applicant's Memorandum and Articles of Association, or equivalent incorporation documents (Part 1)
- Evidence of the applicant’s registration with any other regulatory authority (Part 1)
- A copy of the relevant pages of the relevant person's identification document (to include name, date of birth, nationality, signature, expiration date, and photograph) (Part 2)
- Copy of any relevant degrees, educational certificates, and professional qualifications (Part 2)
- Copy of statement of financial position (and/or financial statements) (Part 3)
  Internal controls and risk management policies and procedures, including digital token management, cybersecurity operations, operational controls, regulatory compliance, reporting policies, code of conduct, etc. (Part 3)
  The completeness and clarity of the information provided in this form will determine the time taken for QFC to review the application.
For any clarification, email: digitalassets@qfc.qa.

Part 1 – Details on Applicant
1. Contact Details
1.a Applicant Company/Individual Name
1.b Address
1.c Telephone Number
Please enter a valid phone number.
1.d Email Address
example@example.com
1.e Website Address
1.f Contact Person Details
Full Legal Name:

First NameMiddle NameLast Name
Business Telephone Number:
Please enter a valid phone number.
Email Address:
example@example.com
2. Business Registration Detail
2.a Business Registration Country
2.b Governing Body(ies)/ Authority(ies)
2.c Business Registration Number
2.d Date of Business Registration

DayMonthYear
2.e Financial Year end
2.f Nature and business activity(ies)
2.g Indicate any business activity(ies) the corresponding details, including the name and jurisdiction of regulator(s) and applicable:
3. Affiliates
3.a Provide a list of all affiliates of the Applicant and indicate nature of relationship, business activities of the affiliate, incorporated jurisdiction, etc. (including Parent Company and Subsidiaries)
4. Declaration
I, hereby affirm that to the best of our information, knowledge, and belief that the contents of Part 1 of Self-Evaluation form and any attachments provided with this form are true, correct and not misleading.
Full Legal Name
Date

DayMonthYear
Signature

Clear

Part 2 - Relevant Persons

(including: Founder, Beneficial Owner, Significant Interests Holder, Directors, and Officers) Please complete part 2 for each Relevant Person
5. Name and Role of Relevant Person/s
6. Personal Details
6.a Residential Address
6.b Date of Birth

DayMonthYear
6.c Citizenship
6.d Identification Type
6.e Identification Number
7. Employment and Education History
7.a Present Employer
Full Legal Name

First NameLast Name
Address
Nature of business
Title of position held
Employment start date

DayMonthYear
7.b Previous Employer (last five years) – Please provide below detail for each employer
7.c List of Full Legal Names of Companies of which the relevant person (if any):
Is a current director or significant interest holder ?
Has been a director or significant interest holder at any time during the last five years ?
7.d Describe any formal education or training obtained by the relevant person in relation to digital asset activities
8. Disclosures
8.a Have you been a Relevant Person, or worked as an employee for any other entity that holds a licence from the QFC?
Provide details
8.b Have you obtained a licence or registration to work in a comparable roles in any other jurisdiction?
Provide details
8.c Have you, or anyone you were associated with as a Relevant Person in any jurisdiction, ever been subjected to disciplinary action by a regulatory body or professional association? Or have you ever been denied admission, registration, or renewal, or had your membership or registration revoked?
Provide details
8.d Have you, or anyone with whom you have been associated as a Relevant Person, in any jurisdiction, ever been declared bankrupt, convicted of a crime, or sued under any law related to fraud?
Provide details
8.e Have you ever been involved in an application for regulatory approval in any jurisdiction that was either refused or withdrawn?
Provide details
8.f Have you been dismissed from any office or employment, or barred from entering any profession or occupation, in any jurisdiction?
Provide details
8.g Has any person you were associated with as a Relevant Person in any jurisdiction, either during your association with them or within one year after you ceased to be associated with them, been compulsorily wound up or made any arrangement with its creditors, or ceased trading without fully settling its creditors' claims?
Provide details
8.h Will you be acting on the directions or instructions of any other person while carrying out your duties?
Provide details
9. Declaration
I, the undersigned, hereby declare that to the best of my knowledge, information, and belief, the contents of this form and any attachments provided with it are true, accurate, and not misleading.

I also authorize the QFC to conduct inquiries and obtain further information as it deems necessary to verify the information provided in Part 2 of the Self-Evaluation Form for the purpose of conducting due diligence and background checks. I understand that the findings of these checks may be disclosed to the person who submitted this application.
Full Legal Name
Date

DayMonthYear
Date
Signature

Clear

Part 3 – Applicant’s Business Plan
10. Detail of Business/Innovation Activities
10.a Business Model
e.g., B2B, B2C, etc.
10.b Revenue Model
e.g., subscription, licensing, markup etc.
10.c Expected Customers (Segment, sector, etc.):
10.d Details and categorization of planned business activities:
10.e Please also provide details on how your proposed products or services align with use case selections or relevance to QFC:
11. Support requested
11.a Please include details of any support you would like to request from QFC:
12. List of Business Partnerships
12.a Provide details of any Business Partnerships, including the nature of relationship, business nature of the partnership and the operating jurisdiction (e.g., joint-ventures, alliances, incubator sponsors, banking partners):
13. Future activities
13.a Does the applicant aim to apply for any other licence with the QFC within a year? If so, which licence(s)?
Provide Details
14. Type of QFC Token Service
14.a Please select one type of QFC Token Service, please specify if selecting others
Provide Details
15. Operational Capabilities

Please provide detailed description of below
15.a Location and capability of Research and Development Resources (Local and Overseas)
15.b Technology Infrastructure
15.c Cybersecurity Protocols
15.d Data Protection, Data Management and Access Management Systems
15.e Risk Management Systems
15.f Regulatory Compliance
15.g Communication Capabilities
15.h Others
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File Upload

Upload all relevent documents. (Accepted file type: pdf, doc, docx, xls, xlsx, zip) | Size Limit: 10 MB
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16. Declaration
16.a
I, hereby affirm that to the best of our information, knowledge, and belief that the contents of Part 3 of Self-Evaluation form and any attachments provided with this form are true, correct and not misleading.
Date:

DayMonthYear
Full Legal Name:
Signature:

Clear

Part 4 – Acknowledgement of Laws, Rules and Regulations
17. Acknowledgement and Unconditional Undertakings
17.a
An acknowledgement that the following laws, regulations and rules will apply to you in relation to your activities in the QFC if recognition is granted, and an unconditional undertaking to comply with those laws, regulations, and rules:
- The QFC Law and Regulations made under it (and in particular FSR, article 82).
- The AML/CFT Law and any regulations made under it; (Note- The AML/CFT Law of the State of Qatar (and any regulations made under it) applies to a recognised exchange as it does to any other entity that operates within the State.)
- Other Laws and Regulations of the State of Qatar that are applicable in the QFC.
- Market abuse and Fees of these rules.
17.b
Unconditional undertakings:
- To submit to the Authority’s exercise of its functions in relation to supervision and investigations (under FSR, Part 8) and disciplinary and enforcement proceedings (under FSR, Part 9), in relation to the applicant’s operations in the QFC;
- To comply with any directions given by the Authority in relation to those operations; and
- To submit to the jurisdiction of the Regulatory Tribunal and the Civil and Commercial Court in relation to the applicant’s operations in the QFC;
17.c
If the law or practice in the applicant’s home jurisdiction requires the applicant to have, in that jurisdiction, 1 or more individuals approved by an overseas regulator to perform a function that is the equivalent of a controlled function:
- A list of those functions and the names of the individuals; and
- Details of the approval of each individual.
18. Shari’a
18.a
If you intend to conduct your business in accordance with Shari’a, your application must include:
- A statement to that effect; and
- A statement of the names of the proposed members of the applicant’s Shari’a supervisory board.
19. Declaration
19.a
I, hereby affirm that I acknowledge the Laws, Rules and Regulations in Part 4 and QFC have the right to audit and reserve the right to amend any applicable rules.
Date:

DayMonthYear
Full Legal Name:
Signature:

Clear
Should be Empty:

Digital Assets - Self-Evaluation Form

Part 1 – Details on Applicant

1. Contact Details

2. Business Registration Detail

3. Affiliates

4. Declaration

Part 2 - Relevant Persons

5. Name and Role of Relevant Person/s

6. Personal Details

7. Employment and Education History

8. Disclosures

9. Declaration

Part 3 – Applicant’s Business Plan

10. Detail of Business/Innovation Activities

11. Support requested

12. List of Business Partnerships

13. Future activities

14. Type of QFC Token Service

15. Operational Capabilities

Upload Documents

16. Declaration

Part 4 – Acknowledgement of Laws, Rules and Regulations

17. Acknowledgement and Unconditional Undertakings

18. Shari’a

19. Declaration