Application Form
for a Participant to Blockchain Telecom
Ecosystem Agreement

This is an Application form for joining the Blockchain Telecom Ecosystem Agreement (hereinafter referred to as the «Agreement»), published on the following website: https://blockchaintele.com/blockchain-telecom-ecosystem-agreement.

Clementvale Baltic OU is a company incorporated in the Republic of Estonia with the registered address at Harju maakond, Tallinn, Kesklinna linnaosa, Estonia pst 5-309B, 10143, registry code 12910090 (hereinafter referred to as the «Administrator»).

The Administrator has a right to refuse to enter into the Agreement with or to provide the Service to any person or Participant on terms set out in Blockchain Telecom Ecosystem Agreement.

(hereinafter referred to as the «Participant»), hereby declares to join the Agreement by signing this Application Form and submitting this Application Form with supporting documents either in written form or electronically to the Administrator.

1. GENERAL INFORMATION ON PARTICIPANT

2. DETAILED INFORMATION ON PARTICIPANT

2.1. ACTIVITY:

Types of Services provided by the Participant
License or permit number (if required by applicable law)

2.1. FOR MOBILE OPERATORS ONLY:

3. SUPPORTING DOCUMENTS

The Participant shall provide the Administrator with Company statutory documents, title documents and licenses, according to the laws of the country of incorporation, for offline validation procedure. The following is an indicative list of such documents:

Certificate of Registration;
An abstract of the Company Register;
Articles of Association/Statute/Charter;
A document confirming Tax Registration Number;
Title documents (Letter of Appointment/Power of Attorney);
Permits and licenses.
Please, specify the list of provided documents at the end of this Application form.

4. DECLARATIONS AND STATEMENTS

By signing this Application Form:

  • The Participant declares that the Participant has read the Blockchain Telecom Ecosystem Agreement and that the Participant is eligible to participate in the Agreement and to provide services, and has all the required licenses and permits under the applicable law.
  • The Participant agrees to be bound by the terms and conditions set out in the Blockchain Telecom Ecosystem Agreement.
  • The Participant authorises the Administrator to keep confidential the provided supporting documents (according to Annex to this Application Form) and agrees that the Administrator has a right to provide such documents upon request of law enforcement agencies.

Company seal

ANNEX

List of Documents Submitted:

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