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[]
[null,"MALTA FINANCIAL SERVICES AUTHORITY",null,null,null,null,null,{"$f":"TODAY()","v":"2019-01-29"}]
[null,"Whitepaper Registration Form"]
[null,"Annex 2"]
[]
[null,"DECLARATIONS SHEET"]
[]
[null,"DECLARATION"]
[null,"We, the undersigned, the VFA and the Applicant, declare that:"]
[]
[null,1,"Whitepaper Registration Form"]
[null,1.1000000000000001,"the VFA Agent is duly authorised by the Applicant to complete and submit this application."]
[]
[null,1.2,"to the best of our knowledge, the information provided within this application is truthful, accurate and complete and that there are no other facts relevant to this application of which the Malta Financial Services Authority (hereinafter, \"MFSA\") should be made aware."]
[]
[null,1.3,"we shall notify the MFSA immediately if the information provided changes in any material way either prior to or subsequent to registration."]
[]
[null,1.4,"the MFSA is hereby being authorised to make such enquiries as it may consider necessary in connection with this application."]
[]
[null,1.5,"we understand that it is a criminal offence, under Article 53(2) of the Virtual Financial Assets Act, to furnish information or to make a statement which one knows to be inaccurate, false or misleading in any material respect, or to recklessly furnish information or to make a statement which is inaccurate, false or misleading in any material respect, pursuant to any of the provisions of this Act or of any regulations made or of any rules issued thereunder, or any condition, obligation, requirement, directive or order made or given as aforesaid."]
[]
[null,2,"Privacy Notice"]
[null,2.1,"we have read the MFSA Privacy Notice and hereby consent to the terms and conditions included therein.  In this respect, the MFSA ensures that any processing of personal data is conducted in accordance with Regulation (EU) 2016/679 (General Data Protection Regulation), the Data Protection Act (Chapter 586 of the Laws of Malta) and any other relevant European Union and national law.  The MFSA Privacy Notice and Privacy Statement are available on the MFSA webpage through the following link: "]
[null,null,"http://www.mfsa.com.mt/pages/viewcontent.aspx?id=672"]
[]
[null,3,"Signatures"]
[null,null,"Kindly note that the declaration should be signed by the Designated Person identified within Section A of this Whitepaper Registration Form and two representatives of the Applicant, which include (i) Administrator/s, (ii) judicial representative/s and/or (iii) other Duly Authorised Representative/s."]
[]
[null,null,1,null,null,"Designated Person"]
[]
[null,null,null,"Name and Surname",null,"Position",null,"Signature                            Date:"]
[]
[null,null,2]
[]
[null,null,null,"Name and Surname",null,"Position",null,"Signature                            Date:"]
[]
[null,null,3]
[]
[null,null,null,"Name and Surname",null,"Position",null,"Signature                            Date:"]
[]
[]
[]
[null,null,"For further guidance on the Application and the respective terms please refer to the Guidance Note to the Whitepaper Registration Form and the Glossary."]

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["Memorandum and Articles of Association","Registered Name ","Current ","Yes","Company ","Entity","List of NCA","Passport","Malta","Executive","Ms","Administrator"]
["Other Constitutional Document","Trade Name ","Past","No","Partnership ","Individual",null,"Identity Card","Afghanistan","Non-Executive","Miss","Other Duly Authorised Representative"]
[null,null,null,null,"Foundation ",null,null,"Registration","Albania",null,"Mrs","Judicial Representative"]
[null,null,null,null,"Association ",null,null,null,"Algeria",null,"Mr"]
[null,null,null,null,"Trusts",null,null,null,"Andorra",null,"Dr"]
[null,null,null,null,"Other",null,null,null,"Angola",null,"Prof"]
[null,null,null,null,null,null,null,null,"Antigua and Barbuda",null,"Ing"]
[null,null,null,null,null,null,null,null,"Argentina"]
[null,null,null,null,null,null,null,null,"Armenia"]
[null,null,null,null,null,null,null,null,"Aruba"]
[null,null,null,null,null,null,null,null,"Australia"]
[null,null,null,null,null,null,null,null,"Austria"]
[null,null,null,null,null,null,null,null,"Azerbaijan"]
[null,null,null,null,null,null,null,null,"Bahamas, The"]
[null,null,null,null,null,null,null,null,"Bahrain"]
[null,null,null,null,null,null,null,null,"Bangladesh"]
[null,null,null,null,null,null,null,null,"Barbados"]
[null,null,null,null,null,null,null,null,"Belarus"]
[null,null,null,null,null,null,null,null,"Belgium"]
[null,null,null,null,null,null,null,null,"Belize"]
[null,null,null,null,null,null,null,null,"Benin"]
[null,null,null,null,null,null,null,null,"Bhutan"]
[null,null,null,null,null,null,null,null,"Bolivia"]
[null,null,null,null,null,null,null,null,"Bosnia and Herzegovina"]
[null,null,null,null,null,null,null,null,"Botswana"]
[null,null,null,null,null,null,null,null,"Brazil"]
[null,null,null,null,null,null,null,null,"Brunei "]
[null,null,null,null,null,null,null,null,"Bulgaria"]
[null,null,null,null,null,null,null,null,"Burkina Faso"]
[null,null,null,null,null,null,null,null,"Burma"]
[null,null,null,null,null,null,null,null,"Burundi"]
[null,null,null,null,null,null,null,null,"Cambodia"]
[null,null,null,null,null,null,null,null,"Cameroon"]
[null,null,null,null,null,null,null,null,"Canada"]
[null,null,null,null,null,null,null,null,"Cabo Verde"]
[null,null,null,null,null,null,null,null,"Central African Republic"]
[null,null,null,null,null,null,null,null,"Chad"]
[null,null,null,null,null,null,null,null,"Chile"]
[null,null,null,null,null,null,null,null,"China"]
[null,null,null,null,null,null,null,null,"Colombia"]
[null,null,null,null,null,null,null,null,"Comoros"]
[null,null,null,null,null,null,null,null,"Congo, Democratic Republic of the"]
[null,null,null,null,null,null,null,null,"Congo, Republic of the"]
[null,null,null,null,null,null,null,null,"Costa Rica"]
[null,null,null,null,null,null,null,null,"Cote d'Ivoire"]
[null,null,null,null,null,null,null,null,"Croatia"]
[null,null,null,null,null,null,null,null,"Cuba"]
[null,null,null,null,null,null,null,null,"Curacao"]
[null,null,null,null,null,null,null,null,"Cyprus"]
[null,null,null,null,null,null,null,null,"Czech"]
[null,null,null,null,null,null,null,null,"Denmark"]
[null,null,null,null,null,null,null,null,"Djibouti"]
[null,null,null,null,null,null,null,null,"Dominica"]
[null,null,null,null,null,null,null,null,"Dominican Republic"]
[null,null,null,null,null,null,null,null,"East Timor (see Timor-Leste)"]
[null,null,null,null,null,null,null,null,"Ecuador"]
[null,null,null,null,null,null,null,null,"Egypt"]
[null,null,null,null,null,null,null,null,"El Salvador"]
[null,null,null,null,null,null,null,null,"Equatorial Guinea"]
[null,null,null,null,null,null,null,null,"Eritrea"]
[null,null,null,null,null,null,null,null,"Estonia"]
[null,null,null,null,null,null,null,null,"Ethiopia"]
[null,null,null,null,null,null,null,null,"Fiji"]
[null,null,null,null,null,null,null,null,"Finland"]
[null,null,null,null,null,null,null,null,"France"]
[null,null,null,null,null,null,null,null,"Top of Page"]
[null,null,null,null,null,null,null,null,"Gabon"]
[null,null,null,null,null,null,null,null,"Gambia, The"]
[null,null,null,null,null,null,null,null,"Georgia"]
[null,null,null,null,null,null,null,null,"Germany"]
[null,null,null,null,null,null,null,null,"Ghana"]
[null,null,null,null,null,null,null,null,"Greece"]
[null,null,null,null,null,null,null,null,"Grenada"]
[null,null,null,null,null,null,null,null,"Guatemala"]
[null,null,null,null,null,null,null,null,"Guinea"]
[null,null,null,null,null,null,null,null,"Guinea-Bissau"]
[null,null,null,null,null,null,null,null,"Guyana"]
[null,null,null,null,null,null,null,null,"Haiti"]
[null,null,null,null,null,null,null,null,"Holy See"]
[null,null,null,null,null,null,null,null,"Honduras"]
[null,null,null,null,null,null,null,null,"Hong Kong"]
[null,null,null,null,null,null,null,null,"Hungary"]
[null,null,null,null,null,null,null,null,"Iceland"]
[null,null,null,null,null,null,null,null,"India"]
[null,null,null,null,null,null,null,null,"Indonesia"]
[null,null,null,null,null,null,null,null,"Iran"]
[null,null,null,null,null,null,null,null,"Iraq"]
[null,null,null,null,null,null,null,null,"Ireland"]
[null,null,null,null,null,null,null,null,"Israel"]
[null,null,null,null,null,null,null,null,"Italy"]
[null,null,null,null,null,null,null,null,"Jamaica"]
[null,null,null,null,null,null,null,null,"Japan"]
[null,null,null,null,null,null,null,null,"Jordan"]
[null,null,null,null,null,null,null,null,"Kazakhstan"]
[null,null,null,null,null,null,null,null,"Kenya"]
[null,null,null,null,null,null,null,null,"Kiribati"]
[null,null,null,null,null,null,null,null,"Korea, North"]
[null,null,null,null,null,null,null,null,"Korea, South"]
[null,null,null,null,null,null,null,null,"Kosovo"]
[null,null,null,null,null,null,null,null,"Kuwait"]
[null,null,null,null,null,null,null,null,"Kyrgyzstan"]
[null,null,null,null,null,null,null,null,"Laos"]
[null,null,null,null,null,null,null,null,"Latvia"]
[null,null,null,null,null,null,null,null,"Lebanon"]
[null,null,null,null,null,null,null,null,"Lesotho"]
[null,null,null,null,null,null,null,null,"Liberia"]
[null,null,null,null,null,null,null,null,"Libya"]
[null,null,null,null,null,null,null,null,"Liechtenstein"]
[null,null,null,null,null,null,null,null,"Lithuania"]
[null,null,null,null,null,null,null,null,"Luxembourg"]
[null,null,null,null,null,null,null,null,"Macau"]
[null,null,null,null,null,null,null,null,"Macedonia"]
[null,null,null,null,null,null,null,null,"Madagascar"]
[null,null,null,null,null,null,null,null,"Malawi"]
[null,null,null,null,null,null,null,null,"Malaysia"]
[null,null,null,null,null,null,null,null,"Maldives"]
[null,null,null,null,null,null,null,null,"Mali"]
[null,null,null,null,null,null,null,null,"Marshall Islands"]
[null,null,null,null,null,null,null,null,"Mauritania"]
[null,null,null,null,null,null,null,null,"Mauritius"]
[null,null,null,null,null,null,null,null,"Mexico"]
[null,null,null,null,null,null,null,null,"Micronesia"]
[null,null,null,null,null,null,null,null,"Moldova"]
[null,null,null,null,null,null,null,null,"Monaco"]
[null,null,null,null,null,null,null,null,"Mongolia"]
[null,null,null,null,null,null,null,null,"Montenegro"]
[null,null,null,null,null,null,null,null,"Morocco"]
[null,null,null,null,null,null,null,null,"Mozambique"]
[null,null,null,null,null,null,null,null,"Namibia"]
[null,null,null,null,null,null,null,null,"Nauru"]
[null,null,null,null,null,null,null,null,"Nepal"]
[null,null,null,null,null,null,null,null,"Netherlands"]
[null,null,null,null,null,null,null,null,"New Zealand"]
[null,null,null,null,null,null,null,null,"Nicaragua"]
[null,null,null,null,null,null,null,null,"Niger"]
[null,null,null,null,null,null,null,null,"Nigeria"]
[null,null,null,null,null,null,null,null,"North Korea"]
[null,null,null,null,null,null,null,null,"Norway"]
[null,null,null,null,null,null,null,null,"Oman"]
[null,null,null,null,null,null,null,null,"Pakistan"]
[null,null,null,null,null,null,null,null,"Palau"]
[null,null,null,null,null,null,null,null,"Palestinian Territories"]
[null,null,null,null,null,null,null,null,"Panama"]
[null,null,null,null,null,null,null,null,"Papua New Guinea"]
[null,null,null,null,null,null,null,null,"Paraguay"]
[null,null,null,null,null,null,null,null,"Peru"]
[null,null,null,null,null,null,null,null,"Philippines"]
[null,null,null,null,null,null,null,null,"Poland"]
[null,null,null,null,null,null,null,null,"Portugal"]
[null,null,null,null,null,null,null,null,"Qatar"]
[null,null,null,null,null,null,null,null,"Romania"]
[null,null,null,null,null,null,null,null,"Russia"]
[null,null,null,null,null,null,null,null,"Rwanda"]
[null,null,null,null,null,null,null,null,"Saint Kitts and Nevis"]
[null,null,null,null,null,null,null,null,"Saint Lucia"]
[null,null,null,null,null,null,null,null,"Saint Vincent and the Grenadines"]
[null,null,null,null,null,null,null,null,"Samoa "]
[null,null,null,null,null,null,null,null,"San Marino"]
[null,null,null,null,null,null,null,null,"Sao Tome and Principe"]
[null,null,null,null,null,null,null,null,"Saudi Arabia"]
[null,null,null,null,null,null,null,null,"Senegal"]
[null,null,null,null,null,null,null,null,"Serbia"]
[null,null,null,null,null,null,null,null,"Seychelles"]
[null,null,null,null,null,null,null,null,"Sierra Leone"]
[null,null,null,null,null,null,null,null,"Singapore"]
[null,null,null,null,null,null,null,null,"Sint Maarten"]
[null,null,null,null,null,null,null,null,"Slovakia"]
[null,null,null,null,null,null,null,null,"Slovenia"]
[null,null,null,null,null,null,null,null,"Solomon Islands"]
[null,null,null,null,null,null,null,null,"Somalia"]
[null,null,null,null,null,null,null,null,"South Africa"]
[null,null,null,null,null,null,null,null,"South Korea"]
[null,null,null,null,null,null,null,null,"South Sudan"]
[null,null,null,null,null,null,null,null,"Spain"]
[null,null,null,null,null,null,null,null,"Sri Lanka"]
[null,null,null,null,null,null,null,null,"Sudan"]
[null,null,null,null,null,null,null,null,"Suriname"]
[null,null,null,null,null,null,null,null,"Swaziland"]
[null,null,null,null,null,null,null,null,"Sweden"]
[null,null,null,null,null,null,null,null,"Switzerland"]
[null,null,null,null,null,null,null,null,"Syria"]
[null,null,null,null,null,null,null,null,"Taiwan"]
[null,null,null,null,null,null,null,null,"Tajikistan"]
[null,null,null,null,null,null,null,null,"Tanzania"]
[null,null,null,null,null,null,null,null,"Thailand"]
[null,null,null,null,null,null,null,null,"Timor-Leste"]
[null,null,null,null,null,null,null,null,"Togo"]
[null,null,null,null,null,null,null,null,"Tonga"]
[null,null,null,null,null,null,null,null,"Trinidad and Tobago"]
[null,null,null,null,null,null,null,null,"Tunisia"]
[null,null,null,null,null,null,null,null,"Turkey"]
[null,null,null,null,null,null,null,null,"Turkmenistan"]
[null,null,null,null,null,null,null,null,"Tuvalu"]
[null,null,null,null,null,null,null,null,"Uganda"]
[null,null,null,null,null,null,null,null,"Ukraine"]
[null,null,null,null,null,null,null,null,"United Arab Emirates"]
[null,null,null,null,null,null,null,null,"United Kingdom"]
[null,null,null,null,null,null,null,null,"Uruguay"]
[null,null,null,null,null,null,null,null,"Uzbekistan"]
[null,null,null,null,null,null,null,null,"Vanuatu"]
[null,null,null,null,null,null,null,null,"Venezuela"]
[null,null,null,null,null,null,null,null,"Vietnam"]
[null,null,null,null,null,null,null,null,"Yemen"]
[null,null,null,null,null,null,null,null,"Zambia"]
[null,null,null,null,null,null,null,null,"Zimbabwe "]