KYC Input Form for Corporate Entities

KYC Input Form for Corporate Entities

Please complete this Know Your Customer (KYC) form for corporate entities applying for NBX accounts and services. All information provided must be true and complete.
Name of corporate entity

NameLegal form
Registration Number
NACE code
Business industry
Does your business need a licence?
Business description
Detailed description of economic activities
Planned operations on the NBX account
Scheme of the company's workflow
Number of employees
Main business partners
Legal address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In what countries does your business operate?
Tax residence
Website, social media sites
What are you planning to use your account for?

Other
Purpose of customer relationship
Please clarify the source of funds for the intended deposit(s)

Other
Do you plan to transfer crypto assets to the NBX wallet?
Provide wallet address from which you plan to transfer
General Managers, Board Members or persons in similar positions
Please specify Name, Middle name, Surname, date of birth
Representative

Natural persons who act on behalf of a legal entity
Name

First NameLast Name
Are you a resident of Norway?
Personal number or ID number
Date of birth

MonthDayYear
Date
For non-residents - Residence
For non-residents - Place of birth
For non-residents - Sex
Citizenship
In case of dual citizenship please indicate both.
Tax residence
In case of more than one please indicate all.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Beneficial owners
Beneficial owner (BO) is a natural person for whose benefit or in whose interest a business relationship is established and for whose benefit or in whose interest all or a separate transaction is made.

NBX must determine whether there are natural persons, alone or in close proximity family members that:

a) owns more than 25 percent of the ownership interest in the legal entity or association;
b) because of the holding of shares, shares or membership controls more than 25 percent of the total number of votes in the legal entity or association;
c) has the right to designate or set aside more than half of the legal person or association;
d) due to an agreement with the owners, members, legal entity or the association, statute or similar, may exercise control in accordance with a) to c) above;
e) otherwise exercises control over the legal entity or association.
Beneficial owner 1
Name

First NameLast Name
Citizenship
Residence Country
Personal number or ID number
Share of Ownership (%)
Date of Birth

MonthDayYear
Date
Is BO1 or his/her family member or close associate a Politically Exposed Person (PEP)?
A politically exposed person is a natural person who performs or has performed prominent public functions, also their family members and close associates. Politically exposed person (a person performing prominent public functions) is:
- a head of state, head of government, minister or deputy minister;
  a member of parliament;
- a justice of the supreme court, constitutional court or another court the judgments of which can be appealed against only in exceptional circumstances;
- a member of the supervisory board of a state audit institution or central bank;
- an ambassador, chargé d’affaires and senior officer of the Defence Forces;
- a member of the directing, supervisory or administrative body of a state company.
A family member of a politically exposed person (a person performing prominent public functions) is:
- his or her spouse;
- a partner equal to a spouse under the law of the person’s country of residence or a person who as of the date of carrying out the transaction had shared the household with the person for no less than a year;
- his or her children and their spouses or partners within the meaning of the previous clause;
- his or her parent.
A close associate of a politically exposed person (a person performing prominent public functions) is:
- a natural person who has a close business relationship with a person performing prominent public functions or with whom a person performing prominent public functions is the joint beneficial owner of a legal person or contractual legal arrangement;
- a person who as a beneficial owner has full ownership of a legal person or contractual legal arrangement, which is known to have been founded for the benefit of the person performing prominent public functions.
Please specify who is the Politically Exposed Person(s)
Please specify relationship (If family member or close associate)
First name, surname of PEP

First NameLast Name
Position of PEP
Institution of PEP
Beneficial owner 2
Name

First NameLast Name
Citizenship
Residence Country
Personal number or ID number
Share of Ownership (%)
Date of Birth

MonthDayYear
Date
Is BO2 or his/her family member or close associate a Politically Exposed Person (PEP)?
Please specify who is the Politically Exposed Person(s)
Please specify relationship (If family member or close associate)
First name, surname of PEP

First NameLast Name
Position of PEP
Institution of PEP
Beneficial owner 3
Name

First NameLast Name
Citizenship
Residence Country
Personal number or ID number
Share of Ownership (%)
Date of Birth

MonthDayYear
Date
Is BO3 or his/her family member or close associate a Politically Exposed Person (PEP)?
Please specify who is the Politically Exposed Person(s)
Please specify relationship (If family member or close associate)
First name, surname of PEP

First NameLast Name
Position of PEP
Institution of PEP
If there is no obligation to specify beneficial owners, mark the reason
Turnover
Corporate entity’s annual turnover last year

Other
Corporate entity’s monthly deposit estimations

Other
What percentage of your total turnover is received in cash
*What is the main source of cash receipts? (e.g., retail sales, services, tips, events)
Required corporate documents of the entity

Please attach the following documents
License (if applicable)

Cancelof
Certificate of registration, which is no more than three months old

Cancelof
Company Share Registry or similar document displaying ownership

Cancelof
If owned by another entity, a Corporate Structure document displaying ownership

Cancelof
The right to act on behalf of the customer (written documentation)

Cancelof
Should be Empty:

KYC Input Form for Corporate Entities

Representative

Beneficial owners

Beneficial owner 1

Beneficial owner 2

Beneficial owner 3

Turnover

Required corporate documents of the entity