Have you ever been convicted of a crime involving fraud or theft?

Yes | No

Have you ever been convicted of a financial crime?

Yes | No

Have you ever filed for bankruptcy or been the subject of insolvency proceedings?

Yes | No

Have you personally reviewed the electronic currency guidelines published by FinCEN?

Yes | No

Have you had an adequate opportunity to consult with your legal counsel about your potential liability relating to money transmission, money services businesses, and financial regulation under federal and state law?

Yes | No

Do you understand and acknowledge that if you use a Device to offer services, you may qualify as a money transmitter or exchanger under federal or state law?

Yes | No

Do you understand and acknowledge that state or federal law may require you to implement certain compliance programs relating to transactions you facilitate on a Device?

Yes | No

Do you understand and acknowledge that you may have compliance reporting requirements under state and federal law?

Yes | No

Do you understand and acknowledge that if you fail to comply with U.S. money transmission laws or regulations, you may be liable for civil or criminal penalties?

Yes | No

Do you understand and acknowledge that Fortomat (including its directors, employees, and agents) has no duty to inform, disclose, advise, warn, or update you regarding federal or state laws covering money transmission or other financial regulation?

Yes | No

Do you understand and acknowledge that Fortomat (including its directors, employees, and agents) are not responsible for your failure to obey any federal or state laws covering money transmission or other financial regulation?

Yes | No

Do you consent to a background check?

Yes | No