Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694878418518.pdf (Antigua and Barbuda)
Antigua and Barbuda Financial Services Regulatory Commission DIGITAL ASSETS BUSINESS APPLICATION FORM Please forward completed questionnaire with any supporting material to: Chief Regulatory Officer Financial Services Regulatory Commission P.O.

Box 2674 Royal Palm Place Friars Hill Road St. John’s, Antigua Tel: (268) 481-1170 ● Fax: (268) 463-0422 Email: CRO@FSRC.GOV.AG Website: http://www.fsrc.gov.ag FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.
16 OF 2020 All parts of this form are to be completed by applicants and shall be submitted, along with any additional information that is required, to the Commission PART A: APPLICANT’S GENERAL INFORMATION INDIVIDUAL APPLICANT CORPORATE APPLICANT ☐ ☐ A1: INDIVIDUAL APPLICANT 1.

Applicant’s full legal name: 2.

Date of Birth of the Applicant: 3.


Current Address of the Applicant: (Please give street address; district/area; Parish/Town/Province; State/Country; Zip code) (Please enter cell, business and home number separated by hyphens) 4.

Email Address: 5.

Contact No.

: 6.

Trading name of business: 7.

Date of registration of the business: 8.

Tax Identification Number 9.

Social Security 10.

Medical Benefits 11.

Are you licensed to conduct digital asset business in any other jurisdiction?
Yes ☐ No ☐ FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.
16 OF 2020 If Yes, please – (a) specify the date on which the applicant began conducting Digital Assets Business (b) state any licence or registration issued (c) provide the name and address of each the regulator(s) which has issued the licence or registration (d) specify the jurisdiction or jurisdictions in which the applicant is conducting business (e) specify whether there are specific requirements, restrictions or prohibitions on the conduct of the activity for which it is registered or licensed; (f) state if any office has been opened or if any physical presence has been established.
12.

State any penalties or enforcement actions that have been imposed or taken against you or any business in which you have or had a controlling interest in another jurisdiction: issued against you or your business?

Do you have a controlling interest in any other business that is engaged in digital asset business activity?

13.

Details of the Compliance Officer: i.

Full name: Other names (aliases) ii.

Personal Address (Mailing and street address): iii.
Date of birth: FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.

16 OF 2020 iv.

Country of birth: v. Gender: vi.

Occupation and job title: vii.

Name of employer: viii.

Street and mailing address of employer: ix.

Phone number of employer: x. Email address of employer: xi.

Professional qualification (Please give a description of your credentials, name of Accrediting body, date of accreditation or graduation and type) xii.

Attach CV or Resume: ☐ xiii.


Address and contact details for the Office of the Compliance Officer: 14.

In relation to the Approved Auditor: (a) Full name (b) Other names (aliases) (c) Personal Address (Mailing and street address) FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.
16 OF 2020 (d) Date of birth (e) Country of birth: (f) Gender: (g) Professional qualification — (i) Description: (ii) Date: (iii) Accrediting Body: (iv) Type: (h) Attach CV or Resume: ☐ NOTE: ALL INDIVIDUAL APPLICANTS MUST SUBMIT THE FOLLOWING AS A PART OF THE APPLICATION ☐ Copy of the individual applicant’s passport Passport #: Where Issued: Issue Date: Expiration Date: ☐ Police record for the individual applicant for any place where the applicant has resided for more than 6 months in the last 15 years; ☐ Copy of the business certificate of registration; ☐ Statement of Particulars for the business; ☐ All documents that may be necessary to establish the information required in this application.
A2: CORPORATE APPLICANT (1) Full name: (2) Date of incorporation: FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.

16 OF 2020 (3) Incorporation number (4) Place of incorporation (5) Address of Corporate Entity: i.

Registered Address: ii.

Business Address: iii.

Mailing Address: (6) Contact information: i.

Telephone number(s): ii.

Fax number: iii.

Email address iv.


Website address (7) If the Applicant was incorporated or established under a different name or is the result of the merger of two or more companies, please provide – (a) previous name or names: i. any trading names (current and previous): FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.

16 OF 2020 ii.
name and registration number for the companies that have merged: Provide as an attachment and properly marked, the following (as applicable): ☐ a copy of articles of incorporation or equivalent documents; ☐ certified copy of the Certificate of Incorporation or Registration or official record of formation, ☐ provide any business names under which the applicant operates, if different from its legal name; ☐ a certificate of good standing (if the company is more than 12 months old); ☐ provide names and copies of a government-issued photo identification for each director and officer: ☐ a corporate organizational chart showing all entities in which the applicant has an interest; ☐ the name of each individual who beneficially holds 5% or more of the applicant.
APPLICANT’S BUSINESS RECORD  Has the applicant ever applied, or held an interest in a business that has applied, to the Commission for a licence?

Yes ☐ No☐  Provide information in the table below starting from the most recent record.

DATE OF APPLICATION TYPE OF LICENCE APPLIED FOR STATUS OF APPLICATION  Does the Applicant conduct or carry out Digital Assets Business from jurisdictions outside of Antigua and Barbuda?
Yes ☐ No☐  If yes, please provide below details of the address outside of Antigua and Barbuda where Digital Assets Business is carried on from.

 Please indicate below the countries in which the Applicant intends to carry on Digital Assets Business.

 Has the Applicant applied to regulatory authorities in other jurisdictions?

CONTINUED ON NEXT PAGE FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.
16 OF 2020 Yes ☐ No ☐ If Yes, please provide details: OFFICERS AND CONTROLLERS  Complete the following table to identify the officers and controllers.

Note that a personal questionnaire form is required to be submitted for each individual.

NAME OF INDIVIDUAL NATURE OF APPOINTMENT DATE OF APOINTMENT SOURCE OF FUNDS  Provide a breakdown of the funds received for the applicant’s business and the source of the funds in the table below.
☐ – The applicant is fully funded by its officers, beneficial owners, controllers and shareholder controllers.

i.

Source of funds: ii.

Type of source (Name and/or Description) iii.

Amount received/ to be received in EC dollar (Name and/or Description)  Shareholder Controllers and Beneficial Owners OWNERSHIP STRUCTURE CONTINUED ON NEXT PAGE FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.
16 OF 2020 Please provide information relating to the shareholder controllers and beneficial owners (natural or legal) of the applicant by listing all shareholder controllers and beneficial owners of the applicant.

A personal questionnaire form is required for each natural person and must be attached to this application: I.

Shareholder controller/beneficial owners name: II.

Percentage of shareholding: III.

Effective date of shareholding: IV.

Entity incorporation number: V. Place of incorporation VI.
Date of incorporation (WHERE THE CONTROLLER QUESTIONNARIE FORM)  Trust Relationships IS AN INDIVIDUAL, MARK “N.A.” AND COMPLETE A PERSONAL  If the Applicant is owned by a Trust(s), please provide as attachments and properly marked, the following information: ☐ Copy of the trust deed ☐ Copy of any supplement deeds removing or adding beneficiaries ☐ Copy of any supplement deeds or appointment and retirement of trustees ☐ Names and addresses of the beneficiaries ☐ Names and current address of the settlor(s) ☐ Names and current address of the trustee(s) ☐ Name and address of the relevant supervisory body that regulates the trustee ☐ Relationship of the settlor to the beneficiaries FINANCIAL STATEMENTS AND AUDITORS  For new companies, to what date will the company make up its first set of audited accounts, and what date will it use annually thereafter?
CONTINUED ON NEXT PAGE FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.

16 OF 2020  What accounting standards will apply to the accounts of the company?

 Who will be the auditors of the company?

Give their details like the name, address, telephone and fax number, including the name of a contact person.

 List the names and addresses of the correspondent banks in which the company has accounts or in which the company intends to have accounts.
 The name, address, telephone and fax number for the principal law firm(s) used by the company in Antigua & Barbuda and/or abroad, including in each case the name of a contact person.

REGULATORY OR OTHER ACTION AGAINST THE APPLICANT  State whether the Applicant has been the subject of any of the following and, if so, provide full details including reasons.

 Refusal of an application for registration, licensing, recognition or authorisation by any authority in any country or jurisdiction?
 Suspension, cancellation or revocation of registration, licence or certificate, recognition or authorisation by any authority in any country or jurisdiction  Regulatory or enforcement action by any authority in any country or jurisdiction FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.

16 OF 2020  Proceedings relating to receivership or creditors' compromise  Provide as an attachment and properly marked, details for any of the questions above to which you have answered yes.
PART B - DIGITAL ASSET BUSINESS ACTIVITY This part is to be completed by all applicants 1.

LICENSE SOUGHT (CHECK ALL BOXES THAT APPLY) (a) Payment Services Provider (b) Digital Asset Exchange (c) Digital Asset Services Vendor (d) Custodial Wallet Services Provider (e) Digital Asset Custody Services Provider (f) Special Purpose Depository Services ☐ ☐ ☐ ☐ ☐ ☐ 2.
DETAILS AND ASSESSMENT OF RISK (a) Identify the main external and internal risks associated with the proposed business activity and the provision of the services for which you are applying to be licensed including data and security risks.
(b) State the name, background and experience of the person that will be responsible for risk management; (c) State what policies have been put in place to identify, assess, monitor and minimize the risks; to inform clients of any breach of their data and other information, and any insurance arrangements that is to be put in place to compensate clients; FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.
16 OF 2020 (d) Provide an outline of the internal safeguards and data protection systems that will be put in place to protect the assets and data of clients; (e) Provide the following documents with the application – compliance manual; anti-money laundering procedures manual; compliance monitoring programme for the business; risk management policies (f) Describe he business continuity and disaster recovery procedures in case of a disruptive event; (g) Please refer to these regulations to see what additional information is required by the Commission in respect of the licensing requirements for a specific activity.
3.

FINANCIAL INFORMATION (a) Provide the most recent audited financial statement for the applicant (Individual and Corporate) (b) Provide details of gross revenue for the last 5 years and Profit after taxes and other payments; (c) Financial year end date: THIS DECLARATION SHOULD BE SIGNED: PART C: DECLARATION (a) In the case of an Individual Applicant, by the Individual applicant in the presence of a an Attorney-at-Law CONTINUED ON NEXT PAGE FORM 1 – APPLICATION FORM DIGITAL ASSETS BUSINESS ACT 2020, NO.
16 OF 2020 (b) In the case of a Corporation, by a Director and the Corporate Secretary or by two Directors and certified by the Companies Accountant.

I/We _____________________________and _______________________________.

Declare that we are duly authorized to make this application.

We confirm that we have read and understood the provisions of the Digital Assets Business Act, No.
16 of 2020 and the provisions of these Regulations, and we declare that the business in respect of which this application is made will be conducted in accordance with the law.

The information contained in this application are true and correct to the best of our knowledge and belief.

Signatures Name and Position with Company Name and Position with Company Date: CERTIFICATION OF APPLICATION I, [Name of Accountant or Attorney-at-Law] certify that: 1.

2.
2.

I have verified the copies of photo ____________________ and have determined them to be true likenesses of the individuals identified thereby; identification provided to me by _____________________ and I have reviewed the [articles of incorporation/other formation documents and a certificate of status/good standing, etc.]

and, based on such review, to the best of my knowledge, __________________________ is a [corporation/trust, etc.]
governed by the laws of _____________________ and is still in existence; 3.

The applicant has included documents meeting all requirements set out by the Regulations in respect of the licence activity which is intended to be covered by the licence.

Sign: Dated: Application must be submitted to the Chief Regulatory Officer at email address CRO@FSRC.GOV.AG