Data collection sheet
for individuals

Please fill out the following form completely.

1. Personal details

Your e-mail address

Date of birth

Nationality

Residence

Residence for the last 5 years

2. Information on the purpose and nature of the business relationship / transaction (please tick as appropriate)

Buy Sell Buy and sell

Bitcoin Ether Similiar

Yes No

3. Explanations (please tick as appropriate)

Yes No

4. Politically Exposed Persons (PEP) (please tick as appropriate)

I am a PEP myself

Yes No

I am a family member of or close to a PEP

Yes No

Information on politically exposed persons to whom I belong as a family member or am otherwise related:

Name

Date of birth

Address

Citizenship

5. Information on the source of funds (please tick as appropriate)

I am currently:

Please upload proof of the source of funds as pdf or jpg. Maximum 10 MB per file. Multiple selection is possible.

Add more documents

Further documents

Löschen

6. Signature

I would like to

sign online upload signature as image

I enclose a copy of an official ID card (both sides) as pdf or jpg with this form and confirm with my signature that all information in this form is correct and complete.

Data collection sheet for individuals

Please fill out the following form completely.

1. Personal details

2. Information on the purpose and nature of the business relationship / transaction (please tick as appropriate)

3. Explanations (please tick as appropriate)

4. Politically Exposed Persons (PEP) (please tick as appropriate)

5. Information on the source of funds (please tick as appropriate)

6. Signature

Data collection sheet
for individuals