Financial Services Auth
Remove an EMD Agent
Notification under Regulation 35 of the Electronic Money Regulations 2011
Name of the electronic money institution (EMI)
Firm reference number (FRN)
Address
Important information you should read before completing this form
This form should only be used to request the FCA remove existing agent(s). It is the responsibility of the
Application
as a
EMI to complete and for
submit Authorisation
this form.
Payment Institution
Filling in the form
1 If you are using your computer to complete the form:

use the TAB key to move from Question to Question and press SHIFT TAB to move back to
the previous Question.
2 If you are filling in the form by hand:

use black ink; and

write clearly.
3 If you think a Question is not relevant to you, write 'not applicable' and explain why.
4 If you leave a Question blank without telling us why, we will have to treat the application as
incomplete. This will increase the time taken to assess your application.
5 If there is not enough space on the forms, you may need to use separate sheets of paper. Clearly
mark each separate sheet of paper with the relevant Question number.
6 This form is to be e-mailed to: [email protected] for UK and EEA agents.
1 Personal details
1
Personal details
1.1 Contact name at the EMI
This is not necessarily the same person making the declaration at the end of the
form
Title
First name(s)
Surname
Job title
Phone number (including STD
code)
Email address
FCA  Remove an EMD agent form  Release 2  March 2017
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2 Removal details for an agent
2
Removal details for an agent
Please use this section if you wish to remove a single agent. If you wish to remove
more than one agent but for different reasons please copy this section as appropriate
and attach it to the form.
2.1 Name of agent
FRN
Postcode
2.2 Reason for removal
End of contract
Termination of Contract by principal
Termination of contract by the agent
Removed for Compliance reasons/fit &proper test
2.3 If the reason of removal is compliance reasons/fit and proper test you
must provide further details below
2.4 Date of removal (dd/mm/yyyy)
/
/
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3 Removal details for multiple agents
3
Removal details for multiple agents
3.1
Do you wish to remove more than one of your agents for the same
reason and with effect from the same date?
NoContinue to Section 2
Yes
3.2
Please list below the names, FRNs and postcodes of the agents you wish
to remove.
Agent Name
1.3
FRN
Postcode
Reason for removal
End of contract
Termination of Contract by principal
Termination of contract by the agent
Removed for Compliance reasons/fit &proper test
1.4 If the reason of removal is compliance reasons/fit and proper test you
must provide further details below
1.5
If you have any additional information to add to the reason above
please attach it to this form.
Attached
1.6 Date of removal (dd/mm/yyyy)
/
/
4 Declaration and signature
4
Declaration and signature
Warning
Knowingly or recklessly giving the FCA information that is false or misleading in a
material particular, may be a criminal offence (regulation 66 of the Electronic
Money Regulations 2011) and may lead to disciplinary sanctions or other
enforcement action by the FCA. It should not be assumed that information is known
to the FCA merely because it is in the public domain or has previously been
disclosed to the FCA or another regulatory body. If you are not sure whether a
piece of information is relevant, please include it anyway.
Data protection
For the purposes of complying with the Data Protection Act 1998, any personal
information set out in this form or attached documents will be used by the FCA to
discharge its statutory functions under the Electronic Money Regulations 2011 and
other relevant legislation. It will not be disclosed for any other purposes without the
permission of the relevant individual.
Declaration
By submitting this notification:

I confirm that this information is accurate and complete to the best of my
knowledge and belief and that I have taken all reasonable steps to ensure
this is the case.

I am aware that it is a criminal offence to knowingly or recklessly give the
FCA information that is false or misleading in a material particular.

I am aware that some questions do not require supporting evidence.
However, the records that demonstrate the applicant firm's compliance with
the rules in relation to the questions must be available to the FCA on
request.

I will notify the FCA immediately if there is a significant change to the
information given in the form. If I fail to do so, this may result in a delay in
the application process or enforcement action.
Name
Position
Signature
Date (dd/mm/yyyy)
/
/
FCA  Remove an EMD agent form  Release 2  March 2017
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