Questionnaire for individuals
I. Chavchavadze Ave. 29
Tbilisi 0162, Georgia
Tel: +995 322 424646
Identification information
First name: *
Your answer
Last name: *
Your answer
Personal No: *
Your answer
E-Mail: *
Your answer
Citizenship: *
In case of other nationality, please, indicate the country
Financial Information
Do you represent a resident of Georgia? *
If "no", please, indicate the country
Are you registered in Georgia as an individual entrepreneur? *
If "yes", please, specify in the bottom row:
What is your occupation?
Please, specify:
Position: *
Your answer
Company name; *
Your answer
Company registration number:
Your answer
Legal status
Are you currently involved in the trial in Georgia, or have you ever been involved in the trial, disputed report or other unspecified issue with other payment system provider in Georgia? *
If "Yes", please specify:
Have you been convicted of a criminal offense? *
If "Yes", please specify:
Information about politically exposed persons
Are you (or your family member, or person related to your business) foreign politically exposed person (PEP) over the last one year? *
If "Yes", please choose from the bottom 3 categories and fill one of the following:
Information about income
Is your business the main source of your income? *
If "No", what is the source of your income?
Monthly Income (in GEL) *
Source of Income *
What purpose do you use/will use eMoney electronic wallet for? *
If "Other", please, describe in detail
Do you use / will use eMoney electronic wallet for your business activity? *
If yes, please, describe how
Do you use another electronic wallet? *
If "yes", please, write down
What is the purpose of transferring your cryptocurrencies (if any)?
Your answer
What is the estimated amount of money you intend to import / export (in GEL) monthly? *
Accuracy of information
Consent *
First name and Last name of person who filled this Questionnaire *
Your answer
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