reg. nr. 10225817


of new user - private person

1. Name ____________________ Surname ____________________
    (given as in accordance with identification document)

2. Personal code/date of birth ________________________________
    (please give DOB in case you do not have a personal code)

3. Residential address ______________________________________
    (please give a residential address or address of registration)

4. Telephone _______________

5. E-mail __________________

6. WMID ____________________

7. Occupation ____________________________________________
    (For example: unemployed, student, an employee of commercial enterprise, office employee, etc.)

8. I am a politically imposed person2, member of his family, close colleague ____
    (please put YES or NO)

Please perform for me a transaction with WebMoney in accordance with terms of CONTRACT OF RECORD (

_______________ _______________
date signature

2 Politically imposed persons:
1) Head of State, of Government, Minister, Deputy Minister and Assistant of Minister;
2) Member of Parliament;
3) Judge of Supreme Court, of Constitutional Court or any other higher courts, whose judgments might be appealed further only in exceptional cases;
4) Board member of state control body and board member of Central Bank;
5) Ambassador, charge d'affaires and higher military officer;
6) Member of management, supervisory and administration bodies of state commercial union.