Full Name of Electronic Money Institution

CENTRAL BANK OF CYPRUS

EUROSYsTEM

NOTIFICATION BY AN ELECTRONIC MONEY INSTITUTION INCORPORATED IN CYPRUS, WISHING TO PROVIDE SERVICES, ON A CROSS BORDER BASIS IN ANOTHER MEMBER STATE IN ACCORDANCE WITH THE DIRECTIVE 2009/110/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL OF
16 SEPTEMBER 2009

FULL NAME OF ELECTRONIC MONEY INSTITUTION

……………………………………………………………….

Details of contact person:

Name
Telephone Number
Fax Number
E-mail address

Who should complete this form

Electronic Money Institutions incorporated in Cyprus, wishing to exercise a passport right to provide services in another Member State, in accordance with the Directive 2009/110/EC of the European Parliament and of the Council of 16 September 2009, should complete this form and submit it to the Horizontal Functions Department, of the Central Bank of Cyprus.

Information on the Payment Institution

Name of Payment Institution: / [name]
Address: / [Head Office Address]
Telephone No: / [tel no]
Fax No: / [fax no]
E-mail address: / [e-mail address]
Contact Person: / [name]
Type of notification: / [first time/changes]
Member State into which services will be provided: / [All EEA States/Name(s) of Host Member State(s)]
Date from which services will be provided: /
[Immediate effect/specific date]

Activitiestobeprovided:

☐ / Issuing electronic money.
☐ / Distribution/Redemption of electronic money.

(Provision of payment services listed in the Annex to Directive 2007/64/EC)

☐ / 1. Services enabling cash to be placed on a payment account as well as all theoperations required for operating a payment account.
☐ / 2. Services enabling cash withdrawals from a payment as well as all theoperations required for operating a payment account.
☐ / 3. Execution of payment transactions, including transfers of funds on a paymentaccount with the user’s payment service provider or with another payment serviceprovider:
- execution of direct debits, including one-off direct debits,
- execution of payment transactions through a payment card or a similar device,
- execution of credit transfers, including standing orders.
☐ / 4.Execution of payment transactions where the funds are covered by a credit linefor a payment service user:
- execution of direct debits, including one-off direct debits,
- execution of payment transactions through a payment card or a similar device,
- execution of credit transfers, including standing orders.
☐ / 5. Issuing and/or acquiring of payment instruments.
☐ / 6. Money remittance.
☐ / 7. Execution of payment transactions where the consent of the payer to execute apayment transaction is given by means of any telecommunication, digital or ITdevice and the payment is made to the telecommunication, IT system or networkoperator, acting only an intermediary between the payment service user and thesupplier of the goods and services.*
* Including granting credits in accordance with the rules provided for in Article 16(3) of the Directive?
☐ yes☐ no

I confirm that the information included in this form is complete and accurate to the best of my knowledge and belief.

Name of authorised signatory:
Position
Signature:
Date: (dd/mm/yy)
This form should be sent to:
CENTRAL BANK OF CYPRUS
Horizontal Functions Department,
Licensing Authorisations Section,
P.O. Box: 25529,
CY-1395 Nicosia,
CYPRUS
TELEPHONE: ++357-22714403
FACSIMILE: ++357-22714940
E-MAIL:
WEBSITE: