Select the type of product you are interested in applying for.

Business Information

US Companies must have an EIN to open an account. All other businesses should have a tax identification number issued by their country of incorporation (a Foreign Tax Identification Number (FTIN)).

Primary Trade/Operations Area (Check all that apply)

Business Overview

Is your business involved in any of the following? (Check all that apply)

a. Currency Exchange (including fiat currencies)

b. Check cashing

c. Issuer of Traveler's checks, money orders or stored value cards

d. Seller or Redeemer of Traveler's checks, money orders, or stored value cards

e. Money Transmitter

f. Internet Gambling

g. Consumer Lending

e. If "NO" was selected in all of the above, check the box to the right

If letter(s) a, b, c, or d was checked above, does your business engage in transactions greater than $1,000 for any person on any day in one or more transactions?

If the answer to e or 3 was "Yes," your business is considered a Money Service Business. Is your business registered in any state as an MSB?

If the answer to f was "Yes," please provide the following information along with this completed application: ▪ State or Tribal issued license that expressly authorizes your business to engage in internet gambling ▪ Signed commitment, disclosure on separate page, agreeing to notify the Bank of any changes in your legal authority to engage in Internet Gambling ▪ Third‐party certification that your systems for engaging in Internet Gambling are reasonably designed to remain within the licensed or otherwise lawful limits, including with respect to age and location.

Has your company been penalized, received a Consent Order or any other decree resulting from a disagreement with the Banking Division or Department in any state?

Account Activity

Purpose Of Account (Check all that apply)

Transfer To/From Other Banks

Other Expected Account Activities (One required, check all that apply)

Deposits

Withdrawals

Authorized Signer Information

A legible copy of the Driver’s License must be provided (front/back) for each Authorized Signer.

Transaction Account Disclosure Information

1. Have you had a transaction account at this or another financial institution within 12‐months before making this application?

Have you had a transaction account closed by a financial institution without your consent within 12‐months before making this application?

Have you been convicted of a criminal offense because of the use of a check or other similar items within 24 months of making this application?

Politically Exposed Persons

Do you have any relatives or close associates in Foreign Government?

History Of Legal Proceedings

If the response to any of the questions in F (1‐5) was "Yes," provide additional information as to the date, persons involved, and circumstances.

Has the applicant, its affiliates, any member of senior management, directors or owners of the company been convicted of a criminal offense?

Has the applicant, its affiliates, any member of senior management, directors or owners of the company been subject to a deferred prosecution agreement?

Has the applicant, its affiliates, any member of senior management, directors or owners of the company been subject to a non‐prosecution agreement?

Has the applicant, its affiliates, any member of senior management, directors or owners of the company been subject to a non‐adjudicated resolution?

Has the applicant, its affiliates, any member of senior management, directors or owners of the company been involved in either a civil or criminal forfeiture?

Signatures

Officers, Control Persons, Ultimate Beneficial Owners

Note: Beneficial owners owning 25% or greater of the entity. A copy of a valid photo ID is required for all listed. Ownership: Please supply the following information for each individual, if any, who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25% or more of the equity interests of the legal entity listed above. Note: If 25% or more of the ultimate beneficial ownership breaks down to an excluded entity (e.g., publicly traded company), note the name of the excluded entity below.. Control: In addition to ownership, please specify at least one individual with significant responsibility for managing the legal entity listed above (i.e., Control Person box must be checked for at least one individual). An individual with significant responsibility for managing the legal entity may be:  An Executive Officer or Senior Manager (e.g., Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer, etc.); OR  Any other individual who regularly performs similar functions.

Client Certification

I hereby certify, to the best of my knowledge, that the information provided above is complete and correct.

Must be signed by: Any Officer if Corporation or Association; Member, Manager or Managing Member if LLC; General Partner if Limited Partnership; Partner if Partnership or LLP.