ANNEXES ANNI APPLICATION FORM NAME OF APPLICANT (as it appears in the wade registration certificate) CATEGORY OF LICENSING BEING APPLIED TOR (please put °X’ in the boxes provided.) MS ‘A) LICENSE FOR (please put * provided) Switch Operator Antomsted Teller Machine Operator [—] in the bor Point of Sale Operator Payment Gateway Operator [=p B) LICENSE RENEWAL [27 ‘APPLICANT'S ADRESS DETAIL PHYSICAL ADRESS : - Klovse umber 6 6! f ‘STREET ROAD 7 + ole Subcit) woreda 98 TOWNICHY | Pcldis Ababa POSTAL CODE PHONE: OFFICE 7 MoB Jtaslqi iia (tog FAX NO, EMAIL AyeANNEX PARTICULARS OF §] OLDERS S. [NAME OF |NATIONALIT [TELEPHONE — [OGCUPATIO [5 OF NW | sHAREHOLDER | Y NUMBER/EMAL | N SHARE 8 L ADDRESS HOLDIN; G 1 WGedion Rirvane HMA felt RAGA |Sodtumve chsh?! SS-2 Yo. | [2 edion Yegeth (206-56) - 265) bputiness cauner | 33-3 %y 3 lesiael Elsie [el ack Yut=Sazo | Sottvate devout 35-5 Yo 4 = = 6 Declaration Tam aware that under sub erticle 2(d) of Article 35 of National Payment System Proclamation ‘No.718/2011 itis an offence to provide false or misleading statement {certify that the information and /or statement given above are complete and accurate to the best of my knowledge, and that there are no other facts relevant to this application of which the National Bank should be aware. | also undertake to inform the National Bank of any charges ‘material to the applications Name Giedion Yove th Signature Date & [30ANNEX IIL EIT AND PROPER PERSON FORM /CONFIDENTIAL/ GENERAL INFORMATION (Influential shareholder, Director, Chief executive officer or Senior executive officer ~ Underline) 1, Name of Payment system Operator 2. Personal information a Fullname Gredion Andieat Yoseph b. Date ofbinth o4{ [25] (v6 © Placcofbinh dive Dawe 4, Nationality EA nie Pies ® Identification card number and date of issue £ Passport number and date ofissue EPSCHE4YAL 93 | OP / AOU 8 a Tax payer Identification Number ae wis rington Address: City Shovelipe _ Sub-city. Zone Woreda, Kebele House No. Postal Address 4/55 Phone Number : Offi Residential: _— Mob: t/ack-$s3-266) Fax:_- Emil i delinumsepgmes con 3+ Educational qualification Regree im pnanayement Tadarmntinn {yoke ea ey J. Summary of Work expetionce No. [Name of Organization | Position Duration /years of work + jANGiA Le | CEO Nowner a Year 3. Please list financial institutions in which you currently (as of completing this form) owns shares inthe following tabl Name of financial | institutions ibscribe shate shares owned Remark Tnnumber [Shares in the financial institution’s total subscribed capital (%)4. Description of your past and current business activities in Ethiopia and abroad (if applicable) Current shareholding or ownership in non-financial institutions /eompanies Nane of | Date "of]Amount of |% from the | Remark the incorporation shate/ownership | total eapitel of ‘company (in BTB the company anloia vel oi loalacet 0% ‘Past shareholding or ownership in a company ( shares you ovmed in the past but had been relinquished) including financial institutions Name of [Dato of | Amount —_of [% fiom the [Reason for | Remark the ‘incorporation | sharefowmership | total capital | termination company Gn ETB of the of share company | holding 5. Uf juridical person (only for influential sharcholders in the payment system Operator), please complete the following table the three recont financial years (please also altaché uxited financial statement) [Year [Asset i Net worth 6. Ifyou are sharcholder of the payment system operator or existing shareholder planning to ‘norease yout shares in the payment instrument issuer, please provide details of the actual ‘source(s of find that, you as a shareholder, Would like to invest or use in the acquisition of shares inthe payment instrument issuerJara Tam aware that under sub article 2(4) of Article 35 of National Payment System Proclamation 'No.718/2011 itis an offence to provide false or misleading siatement {cectiy dat the information and for statement given above are complete and accurate tothe best of my knowledge, and that there ae no otter facts relevent to this application of which the National Bank should be aware, [also undertake to inform the National Bank of any charges ‘atrial othe applications Name_(Fedina Yoseeh Signature Date _9¥|30 a02.4 =ANNEXIV PROPRIETRY TEST QUESTIONNAIRE Flease give Yes or No answers for the following questions and if your answer is “Yes” please sive particulars, FullNane: Gedion Aa dvs Yogoph Cnfiuential sharsholder, ditetor, chief executive officer, senior executive officer- underlying ) ‘Name of Paymen: system operon: GiNGs Eimanciak texknntosy Chan? Cosnpony 1. Hove you or the judicial person in which you were a director, chief executive officer, senior executive fier or ower been charged or convicted of any eximinal offence, particularly an offence relating to dishonesty or frand, under any law whether in Ethiopia or elsewhere? Yes No Ey iFyeas give particulars which you were a director, chief executive officer, senior executive offive or owner been imposed with eomective actions or interventions by public authority due to withholding information or submission of inconect financial or other statements? YesC—] No CEE ityens, give particulars i ee 3. Have you or the juridical person in which you were a director, chief executive officer, senior ‘excutive officer or owner been refused approval by any regulatory/supervisory body of field ‘o comply with roquirements of regulatory éspervisory body? Yes No if yeas, give particulars eS 4 Have you ever been in dispute with previous employees concerning fulfillment of postion or compliance witha code of conduct which has led to imposition of penalty nnder employment oF evor been dismissed oF requested to resign ftom any office of employment or disciplinary measures imposed by trade or professionals? Yes No ifyeas, sive particulars ye ST‘5. Have you been refused, whether in Ethiopia or elsewhere, the right to carry on any trade, business cr profession for which a specifie license, registration or other authority is required? Yes] No CS) yeas, give particulars a 6 Have you othe juridical person in which you were a director, chief executive officer senior exeeutive officer or owner been declared bankrupt whee in Ethiopia or elsewhere or have its asset sequestrated because of banktuptey or foreclosed by a bank due to failure to repay a loa? Yes [=] No CEA tym, give particulars “7. Have you or the juridical person in which you were a director, chief executive office, senior ‘executive officer or aver been convicted of default on repayments of bank or other credits (or tx payment ? Yes [=] No CECT iityeas,piveparticulats 8. Hove you or the jutidical person in which you were a direetor, chief exceutive officer, senior ‘executive officer or owmer been extrying non-performing loan or aecount closed and not ‘einstated by any bank in line with relevant directives of the National Bak? Yes No CBE) ityess, give particulars 9. Has your purchase of shares in payment instrument issuer been funded or to be funded by «another person or legal entity who is actually bankrupted or technically insolvent because of irresponsible or reckless management, fraud of illegal business practice? Yes CJ No CS) ifyess, give particulars 10. Hos your minimum net worth at the tine of acquisition of shares at least greater than the shares aequited or to be acquired from a financial institution? Yes C2] No C251 yeas, give particulars OO 11, Are you currently a member of board of directors or chief executive officer in any of theDeclaration {am aware that under sub article 2(€) of Article 35 of National Payment System Proclamation 'No.71812011 itis an offence to provide false oF misleading, statement ‘cently thatthe information and /or statement given above ace complete and aocunate tothe best of my knowledge, and that there arc no other facts relevant to this application of which the ational Bank should be aware, I also undertake to inform the National Bank of any charges nraterial to the applications, Name_(Fedlan Yooh Stgnatare, Dwte_ovigolamaqNNEXES ANNEX APPLICATION FORM NAME OF APPLICANT ( as i] Mi appears in the tade registation certificate) z CATEGORY OF LICENSING BEING APPLIED FOR (please put *X! in the boxes provided) Atomaal Tele SEE Goon oO Point of Sale Operator Payment Gateway Oporntor == B) LICENSE RENEWAL [=] 3 | APPLICANT'S ADRESS DETAIL PHYSICAL ADRESS Hoge number B Lél=t ‘STREET/ROAD ‘iste, 4 z TOWNCTY fl WN Addis Moab POSTAL CODE PHONE: OFFICE MOB |tasallingass FAXNO, EMAIL | _trasasement @ Wikies (otANNEX It PARTICULARS OF SHARE HOLDERS S” [NAME “OF | NATIONALIT [TREEPHONE | OCCUTATIO [5 ___OF N | SHAREHOLDER | Y NUMBEREMAL | N) SHARE s LADDRESS FOLDIN ¢ i lian & LAtevic.n fi Wha 2 [othe devalue 33-2 Yo) 2 FAwiori e106. 559-265 BuGnese y [3 ESracd Flat [Ameria UH 206 Yar Sain Sf uate lela E38 4 3 6 eclaation 1am avvare that under sub article 2(d) of Article 35 of National Payment System Proclamation 1No.718/2011 itis an offence to provide false or misloading statement Teeitfy thatthe information and /or statement given above are complete acd accurate to the best of my knowledge, and that there are no other facts relevant to this application of which the National Bank should be aware, I also undertake to inform the National Bank of any: charges ‘material 1 the applications Name__E-.Srnel Elaton ‘Signature Date__ 08/30) 202ANNEX IIL EIT AND PROPER PERSON FORM JCONFIDENTIAL/ GENERAL INFORMATION (afluential shareholder, Director, Chief executive officer or Senior exceutive officer ~ Undertine) 1. Name of Payment system Operator 2 Personal information Fallname Esvave\ chatew Etalon Dace ofbith (0/24/1045 Place of bith Addis bebe Nationality mer fcesn ‘dentiication card umber and date of ise Passport mmber and dae of ise “Tax payer Identification Number gegevens Zone HowseNo. Posi) ~ Residential: _~ Mob: 4120 46P-Sos Fa Emil: Svat Gute 5569 Ser. Coir 1+ Eduetional qualification Gavkifeate in Sattware development and Fendi eSSimace , i ummary of Work experignce No.__[ Name of Organization | Position ‘Dutation years oF wk ET Amazon Sotrune OAL S Yeas 3. Please lat nancial institutions ia which you currently (a of completing this form) owns shares inthe following table ‘Name of financial | Subseribe share shares owned Remake institutions Tnnumber [Shares inthe financial institution's total subscribed capital 6)4. Deseription of your past and curent business activities in Ethiopia and abroad (i applicable) 8. Curent shareholding of ownership in non- financial institutions /eompanies Name of] Date Fof| Amount of [% from the | Remark the incorporetion | shareownership | total capital of| compan (nETB the compan Potesheasiud orlotaae [286,008 20°) ‘Past sharcholding or oymership in « company (shares you owned in the past but had ‘been relinguished) including financial institutions Name of [Date of | Amount of |% from the | Reason for] Remark the incorporation | share/ownership | total capital | termination company (in ETB of the [of share company | holding 5. It juridical person (only for influential shareholders in the paymeitt system Operators), please complete the following table the throe recent financial years (please also attaché audited financial statement) Year [Asset Table Net worth 6 Ifyou are sharsholder ofthe payment system operator or existing sharcholder planning to increase your shares in the payment inscument issuer, please provide details ofthe actual source(s) of fond that, you asa shareholder, would like to invest or use inthe aequistion. ‘of shares in the payment instrument issuer,Declaration 4am aware that under sub article 2(d) of Article 35 of National Payment System Proclamation 'No.718/2011 itis an offence to provide fase o misleading statement | certify thatthe information and /or statement given above are complete nd accurate to the best of my knowledge, and that there are no other facts rclevant to this application of which the National Bank should be aware, I also undertake to inform the National Bank of any charges material (othe applications. Name_ESvaet Flaten a ‘Signature Due__08/30 AaaANNEXIV -ROPRIETRY TES 1H Please give Yes or No answers forthe following questions and if your answer is “Yes” please aive yarticulars, Fulltime: ESkxe( Chatew Elale (oflustial shareholder, director, chiof executive officer, senior executive officer- underlying ) ‘Nameof Payment system operator : Gill Bieacial feebroegy Shove Coapaag 1. Hive you or the judicial person in which you were a ditector, chief executive officer, secior ‘ecutive officer or owner been charged or cotvieted of any criminal offence, particularly an offence relating to dishonesty or fraud, under any law whether in Ethiopia ox elsewhere? Yes No ifyeas give particulars a 2. Hive you or the juridical person in which you were a directo, chicf executive officer, senior ‘executive officer or owner been imposed with corrective setions or interventions by public ‘uihority due to withholding information or submission of incorrect financial or other Satements? Yes] No (521 ityeas give particulars a RL seer 3. Heve you or the juridical person in which you wore a director, chief executive oflicer, senior ‘cxeuive olficer ot owner been refused approval by any regulatory/supervisory body of field ‘tocomply with requirements of regulatory /supervisery body? Yes No iftyeas, give particulars i—| oo a ‘+. Have you ever been in dispute with previous employees concerning fulfillment of postion or compliance witha code of conduct whiek has led to imposition of penalty underemployment or ever bee tismssed or requested 10 resign from any office of employment ot discplinary imcasures imposed by trade or professionals? Yes No if yous, give particulars = oo . se eeHave you been refed, whether in Ethiopia or eliewhese, the tight to cary on any trade, twsiness or profession for which a specific leense,registation or other authority is required? YesC—] No E31 ifyeas, give pantiolars a I ii Fave you or the juridical person in which you were &ditector, chief executive oie, senior executive officer or owner been declared bankrupt wither in Ethiopia or elsewhere or have {ts asset sequestrated becauge of bankruptcy or foreclosed by a bank due faire 10 repey # loan? Yeo Cp No CED ifyeas,givepaniouors OT Have you or the juridical person in which you were a ditector, chief exceutive officer, senior ‘executive officer or owmer been convicted of default on repayments of bank or ather credits or tax payment 2 Yes C=] No C7 iftyons, give particulars Hove you or the juridical person in which you were a director, ehiel executive officer senor cxecutive officer or owner been cairying non-performing loan or account elosed and not feinstated by any bank inline with relevant diretives of the National Bank? Yes (=) No CZ) ifyeas, give particulars $$ His your purchase of shares in payment instrument issuer been funded or to be funded by another person or legal entity who is actually bankrupted or technically insolvent because of ieresponsile or reckless management, fraud of illegal business practice? Yeo =] No CEE} ifyeas, give particulars OO Has your minimum net worth at the time of acquisition of shares at least greater than the shares acquired orto be acquited from a financial institution? Yes (No C5E1 yeas, give particulars ne ees een ER EE Are you currently a member of board of directors or chief executive officer in any of the financial institutions or other business? Yes No CAS) ifyeas, give puticulas oeDeclaration ‘Tam aware that under sub article 2(a) of Asticle 35 of National Payment System Proclamation No.718/2011 itis an offence to provide false or misleading statement | certify that the information and /or statement given above are complete and accurate tothe best of my knowledge, and that there are no other facts relevant to this application of which the National Bank should be aware. I also undertake to inform the National Bank of any charges ‘material to the applications. Name_ESyaed Floto Signature Dite__08/30/acoyANNEXES ANNEX APPMICATION FORM NAME OF APPLICANT ( as iW] MS ~ appears in the trade registetion cezrifcate) GLE timaat Be cae Se cama CATEGORY OF TICENSING | — A) LICENSE FOR (plesse’put “X" inthe boi BENG APPLIED oR (iene pa” pve) Seine bnss provide) solth Ogee Avtonatl Tle si Poin of Sule Oper Payee aouy Operate B) LICENSERENEWAL [2] APPLICANT'S ADRESS DETATL PHYSICAL ADRESS haeerRoxp toi Busi f STREET ROAD [Bole Sviecits woreda 0% | TOWNICLTY Addis Arba. be. POSTAL CODE PHONE: OFFICE MOB [rasiquig ise FAXNO. EMAIL ee mas ine comANNEXIN B jOLDERS S| NAME OF |NATIONALIT [TELEPHONE | OGCUPATIO [5 OF N_ | SHAREHOLDER | ¥ NUMBER/EMAL | N SHARE 8 LADDRESS HOLDIN G Beserieag fH sata. [trate dense $3.3 2 Hank 557-2661 [Rasinect auner | 333 % [Anaevicaa |e aek--46f- Soo |S tutare devas 2 Jam aveare thot under sub article 2() of Article 35 of Nasional Payment System Proclamtion ‘No.718/2011 itis an offence to provide false or misleading statement ‘certify that the information and for statement given above are complete and accurate to the best of my knowiedge, and that there are no other facts relevant to this application of which the ‘National Bark should be aware. 1 also undertake to inform the National Bank of any charges ‘material (othe applications Nome aie oe ‘Signature. 5ANNI AT ‘HLT AND PROPER PERSON FORM /CONFIDENTIAL/ GENERAL, INFORMATION (Influential shareholder, Ditector. Chief executive officet jor Senior executive officer ~ Underline) 1. Name of Payment system Operator GIG. Financias Techonoiogy Shure cern paury 2 Personal information & Fullname Gedion Simegnew Rirhane b. Date of birth 06 /26/ (992. Place of bins ANOIS Ababer, Exnohie 4. Nationality American ©. Identification eard: number and date of issue Passport number and date of isste & Tox payer Identification Number cate lashing ton h. Address: City_Shoveline —Subveity. a caw Woreda, Kebele House No, Postal Address 48155 Phone Namber Office; — Residential: _— Mobi 1 4p -622- S92 Fax Bmail,_gedigahivlaneZajmai\ Corn i, Edveutiona quilification Covetiicade in Saduavr slewguannd and — 4 Summary of Work experonee : No. [Namie of Ongnizaion [Pas Diuriion ears of work 3. lense fist financial institutions in which you currently (as of completing this form) owns shares in the following table ‘Name of financial | Subsoribe share sharesowned Remark institutions Innumber —] Shares the financial institution’s total subscribed capital (6)4 Description of your past and current business ectivties in Ethiopia and abroad Gf applicable) ‘Curent shareholding or ovnership in non- nana institutions companies Name of [Date FoF] Amount of [% from the | Remark the incorporation | sharefownersip | total capital of | compan Gn ETB the company [ivetassiud o1lp2/2o1e iS ,.000. oY ». Past shareholding ot oymership in a company (shares you ovened inthe past but had been relinquished) including financial institutions Name “of [Date of | Amount of | % fom the | Reason for | Remaek the incorporation | share/oymership | total capital | termination company (aE of the of shue company | holding 5. Ifjriical person (only for influential shareholders in the payment system Operators), please complete the following table the hrc recent financial years (please also attaché audit Financil statement) ‘Year TAsoet Tiabiies 6. If youre sharoholde ofthe payment system operator or existing shareholder planning to increase your shares inthe payment instrument issuer, please provide details of the etual ‘souee() of find that, vou asa sharcholder, would lke to investor use in the acquisition of shates in the payment instriment issuer, a eae aeDeclaration 1am eware that under sub article 2) of Article 35 of National Payment System Proclamation 'No.718/2011 its an offence to provide false or misleading statement 4 cetty thatthe information and for statement given above are complete and necurate Wo the best of my knowledge, and that there are-no other fae relevant to this application of whieh the National Bank should be aware also undertake to inform the Notional Bank of any charges ‘material to the applicationsANNEX IV PROPRI UESTIONNAIRE, Fletse give Ves or No answers forthe following questions and if your answer is “Yes" please sive partcalars, Fall Nene: _Cedion Sie goeuy Birane (oafluenial shareholder, director, chiofexceutve officer, senior exeeutiveofficer- underlying) Name of Peyment system operator : —Glle Pascal pecbockg? Sjeie Costin |) Have you or the judicial person in which you were a director, chief executive office, senior ‘executive officer or over been charged or convicted of any criminal offence, particularly an ‘offence relating to dishonesty or fraud, under ony law whether in Ethiopia or elsewhere? Yes No gy ifryeas give particulars 2. Have you or the juridical person in which you were a director, chief executive officer, senior xceutive officer or owner been imposed with corrective actions ot interventions by publi authority duc to withholding information or submission of incortect financial or other statements? Yes] No ED fens, give particulars 3, Have you or the juridical person in which you were director, chief executive office, senior ‘xcutive officer or owner been refused approval by any regulatory/supervisory body of field {to comp.y with requirements of regulatory ‘supervisory body’? Yes No iff yeas, give particulars a Have you ever bees in dispute with previous employees concerning fulfillment of position of compliance with a code of conduct which has led to imposition of penalty under employtent ‘or ever teen dismissed or vequested to resign fiom any office of employment or disciplinary ‘measures imposed by trade or professionals? Yes No if'yeas, give particulars ao oc =»5. Have you been refused, whether in Ethiopia or elsewhere, the right to carry on any trade, business or profession for which a specific license, registration or other authority is required? Yes] No C21 ityeas, give particulars aT 6 ‘Have you or he jurdica prson in which you were a decor, che executive officer, sence excentve officer or owner been delaed bankrupt whether in Ethiopia or elaewhore o hove its ase equestated becase of baniuptey or foreclosed by bak du to flre to repay loan? Yes No CE tyes, give particulars 7. Have you or the juridical person in which you wore a director, chief executive officer, senior executive oflier or owner been convicted of deftult on repayments of bank or other credits or tax payment ? ‘Yes [No CE ifyeas, give particulars 8 Have you or the jriical person in which you were a decor, chief executive officer, senior cxceutive offeer or owner been carrying non-performing loan or account closed and not ‘einstated by any bank inline with relevant directives of the National Bank? Yes CJ] No XD ityoas give particntars OO Fis your purchase of shares in payment instrument issuer been funded or to be funded by ‘another person or legal entily who is actually bankrupted or telinieally insolvent because of lmresponsible orreckess management, frad a7 illegal business practice? Yes L—]No EZ] ifyeas, give particulars ne eee ermaniien 10. Has your minimusn net worth at the time of acquisition of shates at least greater than the shares nequired or 10 be acquired from a financial institution? Yes C=] No 1 ityens, give particulars ee 11. Are you euently « member of board of directors or chief executive officer in any of the financial institutions or other business? Yes CJ No CS1 ifyess, give particularsDeclanaton 4 am aware that under sub article (a) of Article 35 of National Payment System Proclamation 'No:718/2011 it isan offence to provide false or misleading siatsment | certify thatthe information and /or statement given above are complete and accurate to the best of my knowledge, and that there are no other facts relevant to this application of which the ‘National Bank should be aware. Lalo undertake to inform the National Bank of any charges ‘material to the applications,