ANNEX ISupplementary provisions
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 Email 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.