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it"},"unit":{"locator":"mica/level-2/its/implementing-technical-standards-standard-forms-templates-procedures-application-authorisation-crypto-asset-service-provider/annex","kind":"annex","key":"annex","heading":"ANNEX — APPLICATION FORM FOR AUTHORISATION AS A CRYPTO-ASSET SERVICE PROVIDER","text":"### ANNEX — APPLICATION FORM FOR AUTHORISATION AS A CRYPTO-ASSET SERVICE PROVIDER\n\nIn accordance with Article 2 and 4 of Commission Implementing Regulation (EU) 2025/306 of 31 October 2024 laying down implementing technical standards for the application of Regulation (EU) 2023/1114 with regard to standard forms, templates and procedures for the information to be included in the application for authorisation as a crypto-asset service provider.\n\nReference number _(to be completed by the competent authority):_\\\nDate:\\\nFROM\\\nName of the applicant:\\\nAddress of the applicant / applicant’s registered office:\\\n_Contact details of the designated contact person_\\\nName:\\\nTelephone:\\\nEmail:\\\nTO\\\nMember State (if applicable):\\\nCompetent authority:\\\nAddress:\\\n_Contact details of the designated contact point_\\\nName:\\\nTelephone:\\\nEmail:\\\nWe, \\[_insert applicant’s name_] declare that the submitted information is true, accurate, complete, up to date, and not misleading. If some information relates only to a future date, it is explicitly identified in the application and we undertake to notify the authority in writing without delay if any such information should turn out to be inaccurate, incomplete or misleading. Further, we undertake to inform the competent authority of any change concerning the information provided in this form.\\\n_Person in charge of preparing the application_\\\nName:\\\nStatus/position:\\\nTelephone:\\\nEmail:\\\nNature of the communication (tick the relevant box)\\\n☐ Authorisation\\\n☐ Notification of changes pursuant to Article 4(1) of Implementing Regulation (EU) 2025/306 (in case of notification of changes, only the relevant parts of the form which are amended should be filled)\\\nREQUIRED INFORMATION\\\nGeneral information according to Article 1 of Commission Delegated Regulation (EU) 2025/305\\\n...\\\nProgramme of operations according to Article 2 of Delegated Regulation (EU) 2025/305\\\n...\\\n_Prudential requirements_\\\n...\\\nPlease insert the information referred to in Article 3 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Information about governance arrangements and internal control mechanisms_\\\n...\\\nPlease insert the information referred to in Article 4 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Business continuity_\\\n...\\\nPlease insert the information referred to in Article 5 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Detection and prevention of_ _money laundering_ _and terrorist financing_\\\n...\\\nPlease insert the information referred to in Article 6 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Identity and proof of good repute, knowledge, skills, and experience and of sufficient time commitment of the members of the management body_\\\n...\\\nPlease insert the information referred to in Article 7 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Information relating to shareholders or members with qualifying holdings_\\\n...\\\nPlease insert the information referred to in Article 8 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_ICT systems and related security arrangements_\\\n...\\\nPlease insert the information referred to in Article 9 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Segregation of clients’ crypto-assets and funds_\\\n...\\\nPlease insert the information referred to in Article 10 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Complaints-handling_\\\n...\\\nPlease insert the information referred to in Article 11 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Custody and administration policy_\\\n...\\\nPlease insert the information referred to in Article 12 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Operating rules of the trading platform and market abuse detection_\\\n...\\\nPlease insert the information referred to in Article 13 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Exchange of crypto-assets for_ [_funds_](https://www.headlesslaw.com/definitions/mica/funds) _or other crypto-assets_\\\n...\\\nPlease insert the information referred to in Article 14 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Execution policy_\\\n...\\\nPlease insert the information referred to in Article 15 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Provision of advice or portfolio management on crypto-assets_\\\n...\\\nPlease insert the information referred to in Article 16 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n_Transfer services_\\\n...\\\nPlease insert the information referred to in Article 17 of Delegated Regulation (EU) 2025/305, by setting out that information here or making reference to the relevant sections of the application.\\\n\\[_signature of legal representative]_\n\n","marks":[],"text_hash":"30533a45d1f9c16ec158b816b8f43198b84d870d7885c745ba81df5b9de7fdcb","revision":1}}