Introduction

This questionnaire is required to be answered on a Legal Entity (LE) level.

Entity & Ownership

Question	Response
1	Legal Name
2	Trade Name
3	Type of Legal Entity
4	Country of incorporation
5	Date of incorporation
6	Registered Address
7	Website
8	Shareholding information

Gambling Details

9	9.a. Gambling Services are offered to (complete as appropriate):	9.b. by when (keep and complete as appropriate)	9.c. by the appropriately licensed Gambling Company mentioned bellow (complete as appropriate):	9.d. based on a valid Gambling License received from the bellow Gambling Licensing Authority (as appropriate)	9.e. Fully aligned to the provisions of bellow Country’s Law governing Gambling (complete as appropriate)	9.f. Based on which the bellow Gambling Services are provided (keep the ones applicable)	9.g. Services Requested by Viva.com (keep the ones applicable)	9.h. Does the Company accept cryptocurrencies?
9.1	country	services currently offered or new offering by MM/YYYY	legal name & title & website	authority name and country	law name and number	Online Sports Betting / Online Casino / Online Lottery / Other (please specify)	Cards Acquiring / Fund Transfers / Card Issuing	Yes ☐ / No ☐
9.2	country	services currently offered or new offering by MM/YYYY	legal name & title & website	authority name and country	law name and number	Online Sports Betting / Online Casino / Online Lottery / Other (please specify)	Cards Acquiring / Fund Transfers / Card Issuing	Yes ☐ / No ☐
9.3	country	services currently offered or new offering by MM/YYYY	legal name & title & website	authority name and country	law name and number	Online Sports Betting / Online Casino / Online Lottery / Other (please specify)	Cards Acquiring / Fund Transfers / Card Issuing	Yes ☐ / No ☐
9.4	country	services currently offered or new offering by MM/YYYY	legal name & title & website	authority name and country	law name and number	Online Sports Betting / Online Casino / Online Lottery / Other (please specify)	Cards Acquiring / Fund Transfers / Card Issuing	Yes ☐ / No ☐
9.5	country	services currently offered or new offering by MM/YYYY	legal name & title & website	authority name and country	law name and number	Online Sports Betting / Online Casino / Online Lottery / Other (please specify)	Cards Acquiring / Fund Transfers / Card Issuing	Yes ☐ / No ☐
9.6	country	services currently offered or new offering by MM/YYYY	legal name & title & website	authority name and country	law name and number	Online Sports Betting / Online Casino / Online Lottery / Other (please specify)	Cards Acquiring / Fund Transfers / Card Issuing	Yes ☐ / No ☐

DECLARATION STATEMENT

I, hereby, declare that the Group where the entity belongs operates through platforms where cryptocurrencies are accepted.

Yes ☐ / No ☐

I attach the Legal Entity’s AML/CTF Policy and KYC Process in place and confirm that additional documents will be provided to VIVA.COM, if requested.

I, ________________________, acting as the legal representative, certify that I have read and understood this declaration and that the answers provided are complete and correct to my honest belief, and that I am authorized to execute this declaration on behalf of ______________________

____________________ (Signature)

____________________ (Place & Date)