reg. nr. 10225817


of new user - foreign legal entity

1. Name _____________________________________________________

2. Registration code or number ____________________________________

3. Place of location _____________________________________________
    (please give a place of location or legal address)

4. Telephone +______________

5. E-mail __________________

6. WMID ____________________

7. Main business activity _________________________________________

8. Territory of activity _________________________________________

9. Sources of financing _________________________________________

10. Basic partners ________________________________________________

11. Prospective annual sum of exchanges ___________________________

12. Connected with 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 position signature name and surname

2Politically 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.