Annex 2 – Notification form for exercising the freedom of establishment

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

Branch details (to the extent available at the time of notification)

• Address 14 • Telephone number
• Email
• Fax number Name(s) and date(s) of birth of natural person(s) responsible for the 15 management of the branch (to the extent available at the time of notification)

To the extent available, services to be 16 provided by the credit intermediary in the host Member State	offers/presents credit agreements assists in preparatory/pre-contractual administration work concludes credit agreements provides advisory services Yes
17 Tied credit intermediary	No

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. Forbhreathnú

Teideal	Rialáil

Ceanglais
Foinse	Ceanglas

Caighdeáin
Foinse	Ceanglas