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Personal Bank Account Application

Please note – the individual on this form will have to be verified. After filling the application ConnectPay reserves the right to ask for additional documents at any time.

Basic personal details

1. First name and last name

2. Country of citizenship

3. Date of birth DD/MM/YYYY

4. Place of birth City, country

5. Type of ID submitted
PassportNational ID
ID no.

ID issue date DD/MM/YYYY

ID expiry date DD/MM/YYYY

ID issue country

ID issue city

6. Personal code

7. PEP1 status Politically Exposed Person. If yes, please state the role/position
YesNo
PEP role/position

8. What is the purpose of the account?Tick the box that is applicable to you
Household expensesPersonal expensesForeign transactionsLoan paymentsGambling fees / charges / winningsVirtual currency related transactionsInvestment related transactionsBusiness related expensesother
If other, please provide more details
9. Will you be the Ultimate Beneficial Owner (UBO)2 of the funds in the account?If no, please fill in APPENDIX A with the UBO’s details.
YesNo

Definitions and explanations

1. Politically exposed person (PEP) definition:    

2. Ultimate Beneficial Owner (UBO) definition:    

Personal contact details


1. Permanent residential address

Address line 1

Address line 2 Optional

Town/City

Postcode/Zip code

Country

2. EmailThis email will be used for verification and communication purposes.

3. Mobile phone number Please include country code. This mobile phone number will be used for verification and communication purposes.

4. Is your communication address different than your residential address?If yes, please proceed to question 5. If no, please proceed to Advanced personal details.
YesNo

5. Alternative mailing address
if different from residential address

Address line 1

Address line 2 optional

Town/City

Postcode/Zip code

Country


Advanced personal details


1. What is your employment status?
Tick the box that is applicable to you EmployedSelf-employed*Unemployed**Retired**Other
Please provide more details.

*If you are self-employed please provide details of your individual business, e.g.: certificate of incorporation.
**If you are retired or unemployed please provide details of your last employment before retirement or unemployment commenced

2. What is your current employer’s name?

3. What is the position you are currently holding?

4. What is your monthly income in Euro?
Or in Euro value


Personal financial details

1. Expected regular monthly total volume of incoming funds in your ConnectPay account in Euro
Or in Euro value

2. Which currencies would you like to have available for payments?Note: for incoming funds only Euro is available.
3. Expected average amount per single payment from
your ConnectPay account in Euro
Or in Euro value

4. Expected highest single transaction amount in the next 12 months incoming or outgoing from your ConnectPay account in Euro Or in Euro value

5. What will be the source of incoming funds into your ConnectPay account?List all possible sources from all your business activities.SavingsAssets investmentsSale of property/assestsPersonal loansLottery / gaming winningsOther
If you checked other, please explain

6. Will your income be paid directly into this account? YesNo
Tax regulations require us to collect information regarding the account holder’s tax residency. We may be required to share this information with the relevant tax authorities.

7. Country of residence for tax purposes

8. Tax Identification Number (TIN)

9. Are there any other tax residency countries?If yes, please state the countries YesNo

Tax residency country

Tax Identification Number (TIN)

10. If a TIN is not available please select the reason applicable The country where the account holder is liable to pay tax does not issue TINs to its residentsThe account holder is otherwise unable to obtain a TIN or equivalent numberThe authorities of the country of tax residence do not require the TIN to be disclosed

11. FATCA statusAre you a US citizen or US tax resident? YesNo

Data protection and declaration


In relation to the GDPR (General Data Protection Regulation) and other applicable legal acts ConnectPay will process the data provided in this online application and any other data which you subsequently give to us in any manner in order to fulfill the agreements between customer and ConnectPay, for the following purposes:

  • To provide, develop or improve our products and services, or otherwise for legitimate business reasons;
  • For internal assessment and analysis (e.g. automated profiling, market and product analysis);
  • If we are under a duty to disclose or share your data to comply with any legal or regulatory obligation; or to protect our rights, property, or safety of our employees, customers, or others. This includes exchanging information with other companies and organizations for the purposes of fraud protection.

Please note that your personal data may, for the above purposes, also be disclosed to or shared with other entities in the ConnectPay group of companies, and other third parties entrusted with providing ConnectPay with due diligence, software development and maintenance, and payment processing services.

ConnectPay may periodically request you to re-confirm the above data, you should inform us immediately if any such data has changed. You have the right to ask us to inform you about the personal data we hold about you, and to request the correction or erasure of that data in accordance with ConnectPay Privacy Policy.

From time to time, we would like to inform you (by post, telephone, fax, e-mail or other electronic means) about our future products and services.

To opt-in to receive such information, please tick this box.

ConnectPay respects your privacy and will not share your personal data with third parties for marketing purposes. For more information please refer to our Privacy Policy.


APPENDIX A – Ultimate Beneficial Owner (UBO) details


Please fill this appendix if you will not be the beneficial owner of the funds in the account.

1. First name and last name

2. Country of citizenship

3. Date of birth DD/MM/YYYY

4. Place of birth City, country

5. Type of ID submitted
PassportNational ID
ID no.

ID issue date DD/MM/YYYY

ID expiry date DD/MM/YYYY

ID issue country

ID issue city

6. Personal code

7. PEP1 status Politically Exposed Person. If yes, please state the role/position
YesNo
PEP role/position

8. Permanent residential address
Address line 1

Address line 2 optional

Town/City

Postcode/Zip code

Country