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?*

YES -> Please attach licence belowNO
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?*

TradingInvestingCustodyPaymentsMoney transfersInvesting in ICO/IEOOther
Purpose of customer relationship*

Cryptocurrency exchangeCustodyStaking
Please clarify the source of funds for the intended deposit(s)*

income and/or interest from main activitiesinvestments of company ownersborrowed fundsThird-party assets held on behalf of clientsICO/IEO (initial coin offering/initial exchange offering)DividendsTrading proceedsMining/stakingOther
Do you plan to transfer crypto assets to the NBX wallet?*

YESNO
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?*

YesNo
Personal number or ID number*
Date of birth*

MonthDayYear
Date
For non-residents - Residence
For non-residents - Place of birth
For non-residents - Sex

MFT
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)?*

YESNO
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)

BO himselfBO family memberBO close associate
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)?

YESNO
Please specify who is the Politically Exposed Person(s)

BO himselfBO family memberBO close associate
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)?

YESNO
Please specify who is the Politically Exposed Person(s)

BO himselfBO family memberBO close associate
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

The customer is a government institutionThe customer is a publicly traded company
Turnover
Corporate entity’s annual turnover last year*

0 - 500,000 USD500,001 - 2,000,000 USD2,000,001 - 5,000,000 USD5,000,000 - 10,000,000 USD>10,000,001 USD (please select 'Other' and specify the amount)Other
Corporate entity’s monthly deposit estimations*

0 - 2 000 USD2 001 - 5 000 USD5 001 - 10 000 USD10 001 - 30 000 USD30 001 - 100 000 USD100 001 - 500 000 USD> 500 000 USD (please select 'Other' and specify the amount)Other
What percentage of your total turnover is received in cash*

0%1 - 5%6 - 15%16 - 30%>30%
*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