Form No. 11 attached to Decree 52/2024/NĐ-CP: Application Form for Reissuance of Payment Intermediary Service License
Form No. 11
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NAME OF THE PROVIDER OF PAYMENT INTERMEDIARY SERVICES
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SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom - Happiness
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……., Date … month … year ……
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APPLICATION FOR REISSUANCE OF PAYMENT INTERMEDIARY SERVICE OPERATION LICENSE
To: Governor of the State Bank of Vietnam.
Pursuant to Decree No. .../.../ND-CP dated... month... year... of the Government on cashless payments and its amendments (if any);
Pursuant to Circular No. .../.../TT-NHNN dated... month... year... of the State Bank of Vietnam on the provision of payment intermediary services and its amendments (if any);
...(1)... requests the State Bank of Vietnam to reissue the payment intermediary service operation license with the following specific details:
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Name of the organization requesting the reissuance of the payment intermediary service operation license:
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Full name in Vietnamese:
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Abbreviated name in Vietnamese (if any):
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Full name in English (if any):
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Abbreviated name in English (if any):
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Trading name (if any):
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Certificate of establishment/Business registration certificate/Business registration certificate No. ... issued by... on... month... year...
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Business code/Tax code:
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Address of the head office, phone number, fax number, email:
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Payment intermediary service operation license already issued No. ... dated... month... year...
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Reason for requesting the reissuance of the license (select the corresponding box):
□ License expiration.
□ License is lost, damaged, burned, or destroyed in any other way.
In case the organization requests the reissuance of the license due to its expiration, the organization must provide documentation proving the maintenance of the conditions for providing the payment intermediary services that were granted under the original license at the time of submitting the reissuance request to the State Bank of Vietnam.
(In addition to the above basic information, the payment intermediary service provider may include other information if necessary)
We commit to complying with and strictly following the regulations of the law and the State Bank of Vietnam; we take full responsibility for the accuracy and truthfulness of the contents in this application and the attached documents (if any). If violated, we accept full legal responsibility.
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Attached documents:
1.
2.
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LEGAL REPRESENTATIVE
(Signature, full name, seal)
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Note: ...(1)... Name of the organization requesting the reissuance of the payment intermediary service operation license.
Download detailed file here.