Bank Account Application Form

BANK ACCOUNT REQUIREMENTS

Account Type*

Payment*

In/Out*

Currency Type*

Current Bank/EMI Accounts

BBVA / N26 / QONTO

Countries to Send/Receive*

Example: Latam/Asia/Europe

Volume per month*

Estimated (EUR)

BUSINESS INFORMATION

Legal Company Name *

Example: Company Name LTD

Website *

Example: https://www.example.net

Registration Number*

VAT Number (if any)*

Registration Address*

Incorporation Country

Address

CityState / Province

Postal Code

E-mail *

Example: ceo@example.net

Whatsapp /Skype /Telegram *

@example

Business Activity*

PERSONAL INFORMATION

UBO (Ultimate Beneficial Owner)

PrefixFirst NameLast Name

Phone Number

Area CodePhone Number

E-mail

example@example.com

Residental Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Citizenship

US CitizenEU CitizenOther

Director(s) Name(s)

PrefixFirst NameLast Name

Phone Number

Area CodePhone Number

E-mail

example@example.com

Residental Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Citizenship

US CitizenEU CitizenOther

Do you want to add joint owner to the bank account?

YesNo

Joint Owner Information (If apply)

Name

PrefixFirst NameLast Name

Phone Number

Area CodePhone Number

E-mail

example@example.com

Residental Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Citizenship

US CitizenEU CitizenOther

Company Documents Required:

Upload Files

1. Articles of Association or Memorandum of Company 2. Certificate of Incorporation or Certificate of Register 3. License (if required for your business or Legal Opinion) 4. Last Company Bank Statement (if any)

UBO/Director(s) Documents Required:

Upload Files

1. Passport of the UBO/Director(s) 2. Proof of Address of the UBO//Director(s) (bank statement or utility bill with less than 3 months)

Primary Owner Signature*

I AGREE:

All details that I have given in the Application form are true and correct, and I shall update mimospay.com immediately if there is any change.

I guarantee have the authorization to sign the Application Form on behalf of the Company and I am not acting as an agent, nominee, or trustee for third parties.

Confirm that:

No directors or shareholders have ever been: convicted of any offense (other than minor offenses); adjudged bankrupt; subject to an investigation by a governmental, professional, or other regulatory body; an officer or shareholder of a business entity which has been the subject of an investigation as aforesaid, or which has been adjudged bankrupt, compulsorily wound up or has made any compromise or arrangement with its creditors.

The company has not been, is not, and will not be involved in, and that its wealth and funds do not derive from, any illegal or criminal activity, including but not limited to money laundering, funding of terrorism, and/or tax evasion.

The company will comply with all applicable laws, including but not limited to Payment Services Directive 2, anti-money laundering and terrorist financing laws, rules and regulations throughout our business relationship

Mimosalecrim LDA and their partners may process my personal data to provide the agreed services and to comply with privacy, card scheme, anti-money laundering, and all other applicable laws.

I also agree that, where applicable, LP MimosPAY also provides or makes such data available to card schemes, acquirers, banks, payment gateway services, and/or other third parties to perform the agreed services.

Where applicable, LP MimosPAY may provide my data to referrers that have to introduce me to mimospay.com only for the calculation of the fees due by MIMOSALECRIM LDA to said referreral and in accordance with the data minimization principle set out by GDPR.

The personal data will be stored in a secure environment for a period of 5 years in order to comply with all applicable laws. At the expiry of such a period, personal data will be destroyed.

The consent is provided for an unlimited period until it is revoked. I may exercise all the rights granted to MIMOSALECRIM LDA by the General Data Protection Regulation (EU) 2016/679 and in particular the right of rectification, erasure, and objection by sending an e-mail to info@mimospay.com In such a case, the provided personal data will be updated, blocked, or deleted unless otherwise required by the applicable laws.

Receiving electronic mail or advertising messages may be revoked in the same manner at any time.

I agree LP MimosPAY may provide us with newsletters and marketing material regarding its services by email, sms, mail or telephone.

I understood that LP GROUP MIMOSPAY IS BRANDING NAME OF MIMOSALECRIM LDA registered in PORTUGAL with office in Lisbon, Barcelona, Bulgaria and Costa Rica.