CAPELLA PAY APPLICATION

Capella Pay Limited (“Capella Pay”) Products & Services Application Form (the “Application”) should be signed by or on behalf
of the Client. It is very important that the Client has read the Application and the declarations set out within in conjunction with the
Agreement (as defined in the “Declarations” section below) before signing. By signing the Application, you are confirming that the details
provided within are correct and that you have read, understood and agreed to be bound by the terms of the Agreement and that the
signatory has the capacity to enter into the agreement on behalf of the applicant (company). Please email completed
Application along with the necessary documents to compliance@capellapay.com
PLEASE COMPLETE IN BLOCK CAPITALS AND ANSWER ALL QUESTIONS

Company Profile

Company name (Full Legal Name):

Trading Name / Doing Business As

(DBA) (if applicable):

Primary Contact for queries related to this application:

Name: Phone Number: E-mail address:

Principal Place of Business:

Street (name and number):

City: County/State/ Post

Province: Code:
Country:

Company Registered Address (If different from above):

Street (name and number):

City: County/State/ Post

Province: Code:
Country:

Website URL(s):

Company Email Address(es):

VAT Number (or Tax

Incorporation Number: Identification Number):
Company Legal Status
Private Limited
Date of Incorporation/Registration: Liability,Public Limited
Liability, General
Partnership, Limited
Company, Proprietary
Date Company began Trading: Partnership etc.

Number of Employees:
Number of Directors/Partners:

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Authorised Representative

Please provide details of each person authorised to instruct or order transactions on behalf of your company for matters related to
this Application and who will be the main contact for this business relationship and attach:
(1) a copy of a valid photo ID (passport or driver’s license), and
(2) a utility bill or bank statement (not more than 3 months old), confirming residential address.

Note: If the authorised representative is not a Director, then please attach an authority for them to act on the company’s behalf
signed by a Director.

First Name: Current home address

Other Names: Street name, No

Last Name: City:

Date of Birth Post Code:

County / State /
E-mail Address:
Province:

Phone Number: Country:

Position in Company: Nationality and Citizenship:

Authority Requested: Reporting Authorising Payments

Operational Contacts / Additional Users

Please give details of any additional contacts who will have authority on the system to access reports and/or to post payments

1 2 3 4

First Name:

Other Names:

Last Name:

Date of Birth:

E-mail Address:

Phone Number:

Position in Company:

Reporting Reporting Reporting Reporting

Authority Requested:
Authorise Payments Authorise Payments Authorise Payments Authorise Payments

** Use this space at bottom of page 2 and mention ALL additional countries that you will be receiving from or sending funds to,
Please Include the Percentage split.
** (Incoming Payments)
Currencies and Countries

** (Outgoing Payments)
Currencies and Countries

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Business and Transaction Information

Please describe your Products or

Services and Business Model,
Including Main Business Regions,
EEA, Asia, Africa, Russia, The
USA, Canada please provide is
other.
This will allow Capella Pay to better
understand your business and
potential needs, and also speed up
your onboarding process.
Please feel free to attach additional
pages or use space on Page 9.
Number of Additional Pages?
__________________________________________________________________________
Last Years Turnover
__________________________________________________________________________
Next Years Estimated Turnover

Incoming Funds *

Source / Purpose of Incoming Funds

___________________________________________________________________________
Main Business Partners, Suppliers,
Customers etc.
Number of Customers / Clients, by category: Individuals: Corporates:
Total Amount to be Received per Month:
Individuals: Corporates:
SPECIFY CURRENCY:
Number of Payments per Month: Individuals: Corporates:

Average individual payment value: Individuals: Corporates:

Payments to be Received from which countries: **

Percentage split by Country:

Outgoing Payments *

Purpose for Outgoing Payments

________________________________________________________________________
Main Business Partners, Suppliers,
Customers etc.
Number of Payees / Clients, by category: Individuals: Corporates:
Total Amount to be Sent per Month:
Individuals: Corporates:
SPECIFY CURRENCY:
Number of Payments per Month: Individuals: Corporates:

Average individual payment value: Individuals: Corporates:

Payments to be Sent to which countries: **

Percentage split by Country:

* attach a spreadsheet if required.

** use space at bottom of page 2 and mention ALL additional countries that you will be receiving from or sending funds to,
Please Include the Percentage split.

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Regulated Entity

Does your product or service require regulatory approval?

(such as the Financial Conduct Authority in the UK)
If so, who is the Regulatory Authority?
Please include the Country the Regulatory Authority is
based in
Please specify if any other local or international regulation
applies to your business model:

Please provide your Regulatory Registration / Licence

number and details.

Service Requirements

Please indicate which of Capella's Services you would like to use. Capella Pay will provide firm quotations of rates, set-up
requirements, file format instructions, and relevant service agreements in due course. Some of these services will be provided
through Capella's business and payment partners. Do not hesitate to contact us with questions about any of our services.
Further information can be found at: www.capellapay.com

Services
UK Faster Payments (GBP) SEPA (Euro) SWIFT ✔
Card Services Debit Card Credit Card
Client Safeguarding Account Card Acquiring Services for Merchants / Clients
Corporate IBAN Cross-Border Payment Solutions
Personal IBAN FX Services (including FX and forward Remittance Globally)
Bulk IBAN Services Trading in Digital Assets

IBAN: In which currencies do you wish

Pound Sterling (GBP) Euro (EUR) US Dollars (USD)
your Accounts to be maintained / issued ?

Bank Account Details

Please give details of the company bank account for the transfer of funds to or from Capella Pay (* fill in applicable)

Bank Name

Bank Address:
Sort Code / Transit / ABA
No:

Account Name:

* Account Number:

* IBAN:

SWIFT Code / BIC:

Currency of Account:

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Company Directors

Depending on your business type we require information from the following Principals to complete this section:

• in the case of a sole proprietor, the sole proprietor;

• in the case of a partnership, all partners;
• in the case of a Limited Partnership, the general partner;
• in the case of a Limited Company all directors.

Please attach further sheets if required

Director 1 Director 2 Director 3 Director 4

First Name

Other Names:

Last Name:

Date of Birth

E-mail Address:

Phone Number:

Current home address:

Street name, No:

City:

Post Code:

County/Province/State:

Country:

Nationality:

Please attach further sheets if required.

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Ultimate Beneficial Owner

Please confirm the Shareholders and Ultimate Beneficial Owners. For trusts all parties with beneficial voting rights will need to be
identified.

Shareholders will be classified as beneficial if they hold 10% or more of the total share or voting rights. If the beneficial owner of a
company is another company or legal entity we will require an explanation to identify a natural person/s as beneficial owner.

Beneficial Owner 1 Beneficial Owner 2 Beneficial Owner 3 Beneficial Owner 4

First Name

Other Names

Last Name:

Date of Birth

E-mail Address:

Phone Number:

Current home address:

Street name, No:

City:

Post Code:

County/Province/State:

Country:

Nationality:

% Ownership:

Please attach further sheets if required

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Company Group Status

Is the applicant company a member of a group of companies either as a subsidiary or a parent company?

If yes, please provide details on the other companies in the group and their relationship to the applicant company and
Please also provide an Organisational Chart.

Name of Group company Relationship to Country/Jurisdiction Are there common Are any of the
(please include any trading applicant company company is registered in. directors with applicant group companies
name) (Parent, Subsidiary, company (if yes please regulated (if yes
Related group member) name) please provide
details for
Example the FCA)

Please attach further sheets if required

PEP - Politically Exposed Person

Do any of the above-named Directors, Shareholders, UBO’s or any members of their family hold a politically exposed
position or are they close associates or cohabitants of anyone who holds a politically exposed position ?

A politically exposed position is a head of state or government minister, senior politicians. A member of the executive
council or legislature, senior bureaucrat or government official. Ambassador, embassy attaché or counsellor. A high-
ranking officer in the armed forces. A member of the administrative management or supervisory body of a state-owned
enterprise. A member of a court of auditors or the board of a central bank. A head of a government agency. A member of a
supreme court, constitutional court or high level judicial body.

If yes, please name the person(s), position held by the PEP and the relationship:
Yes

No

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Supporting information for Application

Please provide the following Required Documents which must be accompanied with this Application (Form A) and the EDD
Questionnaire (Form B).

Corporate Documents:
1. Certificate of Incorporation
2. Memorandum and Articles of Association
3. Copy of Register of Directors
4. Copy of Register of Shareholders
5. Certificate of Good Standing / Certificate of Incumbency (where applicable)
6. Copy of Company bank statement (last 3 months)

Individual(s) Documents:

7. Individual verification of all active Directors (POI, POA)

8. Individual verification of Shareholders / Beneficial Owners with a holding of 10% or more (POI, POA)
9. Individual verification(s) of All Authorised Users on the Account (POI, POA)

NOTE: Where the Authorised Representative is not a Director of the company, a Director will need to confirm in writing the
name and authority of the of the person responsible for the administration of the account and we will need;

10. Individual verification of Authorised Representative (POI, POA)

NOTE: In instances where the Entity is required to be Licensed and/or Regulated, we need;

11. Copy of any Licence(s)

12. Copy of Authorisation document from the relevant Regulatory body
13. AML and KYC Policies and a CV for the MLRO or Head of Compliance

NOTE: For Corporate shareholders (where the registered shareholder is another company), we need;

14. All of the above (1-12) for all Parent companies

15. Organisational Chart

NOTE: In certain cases, other information or documents may be requested if required during the onboarding process, e.g.

 Certification of Documents
 A copy of the Business Plan, A Legal Opinion of the business model
 Meeting in person, Video call, A Selfie with your passport
 CV / Resume, Professional References
 Source of Funds declaration
 An Additional Proof of Identity and Proof of Address

Supporting Documents Guideline:

 POI - Proof of ID (valid passport or other government issued photo ID in colour)
 POA - Proof of Residential Address (utility bill or bank statement dated within the last 3 months clearly showing the
Name and physical Address, (P.O. box address is not acceptable)
 All Documents must be in English. Where translated, they must be certified by a competent authority.

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How did you hear about Capella Pay ?

Referred by another company: Which company?

Referred by an individual: Which individual?

Magazine Advertisement: Which magazine?

Online Advertisement: Which website?

Online Search: Which keyword?

Tradeshow: Which tradeshow?

Other: Please specify

Use this space to add any Comments, Queries or Additional Information.

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Important Notice

Thepersonal information thatwecollectin thisapplication form and during thelifetimeof your accountiskeptprivate. We collect personal information
to determine your eligibility for products and services, to ensure high service standards, to meet regulatory requirements, and to verify your identity.
Personal information you provide to Capella Pay Limited willnotbeusedin anycommercialwayandwillnotbeprovidedtoanyoneelseexceptin
responsetoarequest fromregulatory, governmental or law enforcement agencies, orwith our businesspartners and service providers to assistus
in providing services to you. These business partners and service providers may be located within or outside of the European Economic Area.
Whenever we request services from our business partners, we enter into a contractual agreement to ensure confidentiality and share the leastamount
ofinformation needed toperform therequired task. A copy of Capella Payprivacypolicyisavailableupon request.

Capella Pay Limited (Capella Pay) designs and operates the Capella Pay websites and app. The Capella Pay business current account is an e-
money account provided by Syncom (UK) Limited (Syncom) which is an electronic money institution authorised and regulated by the Financial
Conduct Authority under the Electronic Money Regulations 2011 (FRN 932543) for the issuance of electronic money. Syncom holds an amount
equivalent to the money in Capella Pay current accounts in a safeguarding account with Clear Bank Ltd who are authorise by the Prudential
Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority (Financial Services Register
number: 754568). This in accordance with the Electronic Money Regulations 2011 gives customers protection against Syncom’s insolvency.

Capella Pay may request additional documentation after review of this Application Form.

Capella Pay may request relevant URLs or other relevant promotional material along with completed and signed service agreements beforewe can set
up accounts or process payments on your behalf. If service agreements have not been sent to you already, theywill be issued based on information
provided in this Application Form.

Declarations

Words and expressions used in this Application will, unless otherwise defined in this Application, have the same meaning
as set out in the Terms and Conditions. By signing this Application, you are:
• Confirming that you are duly authorised to sign for and act on behalf of the Company and no consent or approval is
required from any other person.
• Confirming that the information that you have provided in this Application is accurate and correctly reflects the
profile, products and services of your business and the payment services you wish to receive. You further confirm
and agree that you will notify Capella Pay in good time of any changes to the information provided herein.
• Agreeing to and authorising the searches, due diligence enquiries and use of your information as set out in
the Privacy Policy and Framework Terms for Payment Services.
• Acknowledging and agreeing that you have read and are bound by the terms of the Agreement (comprising this
Application, the Framework Terms, and such other documents as the two parties may from time to time agree which
together shall constitute the entire Agreement between the parties).

Signature

I certify the above information to be true and correct:

Signature:

Print name:
Position:

Date:

Capella Pay Payments

Office Only:
Applicant’s Contact:
Case Officer, Checked/Approved by:

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