# ANNEX — APPLICATION FORM FOR AUTHORISATION AS A CRYPTO-ASSET SERVICE PROVIDER **Commission Implementing Regulation (EU) 2025/306 · binding · OJ L, 2025/306, 31.3.2025 · dated 31 Oct 2024 [in force]** *In force · Commission Implementing Regulation (EU) 2025/306, OJ L, 2025/306, 31.3.2025 · Checked against EUR-Lex on 26 Oct 2026 · [Official source](https://eur-lex.europa.eu/eli/reg_impl/2025/306/oj/eng)* In 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. Reference number _(to be completed by the competent authority):_\ Date:\ FROM\ Name of the applicant:\ Address of the applicant / applicant’s registered office:\ _Contact details of the designated contact person_\ Name:\ Telephone:\ Email:\ TO\ Member State (if applicable):\ Competent authority:\ Address:\ _Contact details of the designated contact point_\ Name:\ Telephone:\ Email:\ We, \[_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.\ _Person in charge of preparing the application_\ Name:\ Status/position:\ Telephone:\ Email:\ Nature of the communication (tick the relevant box)\ ☐ Authorisation\ ☐ 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)\ REQUIRED INFORMATION\ General information according to Article 1 of Commission Delegated Regulation (EU) 2025/305\ ...\ Programme of operations according to Article 2 of Delegated Regulation (EU) 2025/305\ ...\ _Prudential requirements_\ ...\ Please 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.\ _Information about governance arrangements and internal control mechanisms_\ ...\ Please 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.\ _Business continuity_\ ...\ Please 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.\ _Detection and prevention of_ _money laundering_ _and terrorist financing_\ ...\ Please 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.\ _Identity and proof of good repute, knowledge, skills, and experience and of sufficient time commitment of the members of the management body_\ ...\ Please 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.\ _Information relating to shareholders or members with qualifying holdings_\ ...\ Please 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.\ _ICT systems and related security arrangements_\ ...\ Please 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.\ _Segregation of clients’ crypto-assets and funds_\ ...\ Please 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.\ _Complaints-handling_\ ...\ Please 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.\ _Custody and administration policy_\ ...\ Please 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.\ _Operating rules of the trading platform and market abuse detection_\ ...\ Please 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.\ _Exchange of crypto-assets for_ [_funds_](https://www.headlesslaw.com/definitions/mica/funds) _or other crypto-assets_\ ...\ Please 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.\ _Execution policy_\ ...\ Please 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.\ _Provision of advice or portfolio management on crypto-assets_\ ...\ Please 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.\ _Transfer services_\ ...\ Please 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.\ \[_signature of legal representative]_