Annex 1 – Notification form for exercising the freedom to provide services

Date of transmission of this notification 1 from the home to the host competent DD/MM/YYYYY authority

2 Host Member State

3 Type of notification

First notification Change to previous notification

4 Name of credit intermediary

5 Date of birth in case of natural person DD/MM/YYYYY

6 Home State registration number

7 Head office address

8 Email

9 Telephone number

10 Fax number

11 Name of home competent authority

12 Home Member State

13 Web address of the online register

To the extent available, services to be 14 provided by the credit intermediary in	offers/presents credit agreements assists in preparatory/pre-contractual administration work
the host Member State	concludes credit agreements provides advisory services Yes
15 Tied credit intermediary	No

16 In the case of a tied credit intermediary:

a) Name and registration number of a) ………………………………………………….. the creditor(s) or groups to which the intermediary is tied in the host Member State
b) Whether the credit intermediary is b) ..................................................... exclusively tied to only one creditor
c) Confirmation that the creditor(s) c) ..................................................... take full and unconditional responsibility for the credit intermediation activities

1. Overview

Summary	Regulation

Requirements
Source	Requirement

Standards
Source	Requirement