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Section 1
Date:
1FSTPOBMJOGPSNBUJPO
. Full name:
. ID number:
Driver
. ID type: Passport ID card
licence
. ID dates (DD/MM/YYYY)
From (issue date) To (expiration date) . ID issuing country:
. Home SFTJEFOUJBM
address:
. Citizenship: . Registered Email:
1. Personal taxpayer number / Social Security Number
. Phone number: (or any other tax reference number if applicable):
11. Link to social network profiles:
11.1 Facebook:
11.2 LinkedIn:
11.3 Other:
SIGN______________________________________
Section 2
&NQMPZNFOU
1. What is your employment status? Employed Self-employed Unemployed
If you checked &NQMPZFE please specify:
1. Name of employer: 2. Type of business:
3. Employer address:
4. Employer phone: 5. Your position:
7. Employer website:
6. How long have
you been employed: years
If you checked 4FMGFNQMPZFE please specify:
1. When you became a selfemployed person 2. Type of business:
(DD/MM/YYYY)
3. Tax reference number: 4. Registration number (if any):
SIGN______________________________________
Section 3
4PVSDFPGGVOET
1. Check the sources of your fiat funds:
Salary Savings Trading income Rent income
Return on investment Loan *Other
*If you checked 'other'
please clarify:
! Please provide any financial documentation to support your statement with your reply.
2. What is your monthly income (in equivalent):
From $ 1.001.00 From $ 5.001.00 From $ 10.001.00
Below $ 1.000.00 to $ 5.000.00 to $ 10.000.00 to $ 25.000.00
From $ 25.001.00 From $ 50.001.00
Above $ 100.001.00
to $ 50.000.00 to $ 100.000.00
3. If you are planning to deposit cryptocurrency, please describe its source:
Mined Bought
If bought, where:
4. If you are planning to withdrawal cryptocurrency, please describe its source:
Other exchange My own crypto wallet *Other
*If you checked 'other'
please clarify:
SIGN______________________________________
Section 4
1BZNFOUEFUBJMT
Please, provide us information about your bank which you intend to use to make
deposits and withdrawals:
1. Bank name: 2. Bank address:
3. Bank Account Number: 4. IBAN:
5. SWIFT 6. Are you going to use a bank card for deposits?
*Yes No
*If you checked 'Yes', please tell us, whether you intend
to make deposits for amount above
1,000 USD/EUR per day?
**Yes No
**If you checked 'Yes', please tell us approximate amount
of daily deposits via bank card (in USD/EUR):
SIGN______________________________________
Section 5
2VFTUJPOOBJSF
1. What is the primary purpose of this account?
Trading Investment Savings *Other
*If you checked 'Other'
please describe:
2. What is primary use of crypto funds?
3. What is the estimated amount that you are planning turnover on CEX.IO account per month?
From $ 10.001.00 From $ 25.001.00
Below $ 10.000.00
to $ 25.000.00 to $ 50.000.00
From $ 50.001.00 Above $ 100.001.00
to $ 100.000.00
4. Are you a Politically Exposed Person (PEP)? 5. Are you a family member or a close associate
of PEP?
Yes No Yes No
If yes, describe your position: If yes, describe your relationship and his/her position:
SIGN______________________________________
Section 6
%FDMBSBUJPO
I hereby certify that the information provided in this application form is true and accurate.
I agree that if the application approved I will be bound by CEX.IO Terms of Use (https://cex.io/terms) and all
applicable policies, limits and conditions and will not use the CEX.IO service to commit a fraud or violate any
laws.
I authorise CEX.IO LTD to use, process and keep all information it obtains from me for auditing, risk assessment,
fraud and crime prevention measures.
I undertake to inform CEX.IO in writing of any changes in the information provided herein and I agree to
provide CEX.IO documents that prove the source of my funds upon reasonable request.
SIGNED BY Name:
Date:
