ANNEX I
Form for the investment services and activities passport notification and the change ofinvestment services and activities particulars notification (1)
(Articles 3 and 6 of Commission Implementing Regulation (EU) 2017/2382)
Reference number:
Date:
Part 1 — Contact Information
Type of notification:
Investment services and activities passport notification/change of investment services and activities particulars notification
Member State in which the investment firm/credit institution intends to operate:
Name of investment firm/credit institution:
Trading name
Address:
Telephone number:
Email:
Name of the contact person at the investment firm/credit institution:
Home Member State
Authorisation Status:
Authorised by [Home Member State Competent Authority]
Authorisation Date:
Part 2 — Programme of operations
Intended investment services, activities and ancillary services (*)
Investment services and activities
Ancillary services
A1
A2
A3
A4
A5
A6
A7
A8
A9
B1
B2
B3
B4
B5
B6
B7
Financial Instruments
C1
C2
C3
C4
C5
C6
C7
C8
C9
C10
C11
(*) Please place an (x) in the appropriate boxes.
(1) For the purposes of a change of investment services and activities particulars notification please complete only the parts of the form which are relevant to the notified changes. If the intention is to make changes to the investment services, activities, ancillary services or financial instruments, please list all the investment services, activities, ancillary services or financial instruments the firm will provide.
Details of Tied Agent located in the home Member State (*)
Name of thetied agent
Address
Telephone
Contact
(*) Please provide separate matrices with the intended investment services for each tied agent the investment firm intends to use.
Intended investment services to be provided by the tied agent (*)
Investment services and activities
Ancillary services
A1
A2
A3
A4
A5
A6
A7
A8
A9
B1
B2
B3
B4
B5
B6
B7
Financial Instruments
C1
C2
C3
C4
C5
C6
C7
C8
C9
C10
C11
(*) Please place an (x) in the appropriate box(es). If you intend to make changes to the investment services, activities or financial instruments provided by the tied agent, please list all investment services, activities or financial instruments the tied agent will provide.