S21 Application Form |

Don’t invest unless you’re prepared to lose money. This is a high‑risk investment. You may not be able to access your money easily and are unlikely to be protected if something goes wrong. Take 2 mins to learn more.

S21 Application Form

Thank you for considering rebuildingsociety.com Ltd as your S21 FP Approver. Please be aware that rebuldingsociety.com is required not to approve any financial promotions in respect of cryptoassets at this time. For more information, please see the restrictions on our permissions here. We have appealed these restrictions and await the outcome of the Upper Tribunal. If you apply to work with us, we will assist you with the compliance requirements to ensure your firm does not target UK customers. We will queue applications and process them in the order received. While we are hopeful to have our permissions reinstated, we cannot confirm if or when this will happen.

We have developed this online application to collect information about your business to inform our due diligence assessment.

When you are ready to submit your application, you will be invoiced the application fee of £5,000 + VAT and invited to pay online using Open Banking. Payment is to be received before your application can be fully considered.

To assist, we have created a short guidance document.

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Application

1.Contact Details	[NOT STARTED]
2.Permissions and Business Details	[NOT STARTED]
3.Firm’s Details	[NOT STARTED]
4.Regulatory Status of Company	[NOT STARTED]
5.Firm Trading and Share Structure Details	[NOT STARTED]
6.Firm Financial Details	[NOT STARTED]
7.Firm’s Assets and Liabilities	[NOT STARTED]
8.Business Structure	[NOT STARTED]
9.Product & Market Details	[NOT STARTED]
10.ESG Assessment	[NOT STARTED]
11.Existing System	[NOT STARTED]

1.Contact Details

Name of Main Contact Person:
Position:
Telephone Number:
Mobile Number:
Email Address:

2.Permissions and Business Details

Is your business regulated in any jurisdiction:

What type of crypto assets does your firm offer / trade?

	Stablecoins
	Commodity Backed assets
	Complex Yield assets
	NFTs
	Security Tokens
	Other

Do you, or have you in the past, marketed your assets to UK consumers?

Have you ever been issued an enforcement notice or any such warning from the Advertising Standards Authority (ASA) or Financial Conduct Authority (FCA), or any other regulatory body, for any promotions or adverts that you have published in the past?

To fully assess your application, we will need to review your white paper.
Please upload the most recent version of your whitepaper here.

Do you operate an exchange?

If you offer a cryptoasset of your own, which exchanges do you work with?

3.Firm’s details

Business Name:
Trading Name used or intended to be used by your firm:
Please list any other names that your firm has previously used:
Country of Incorporation:
Location of Head Office:
Legal Status:
Incorporation Date (Ltd Co’s Only):
Registration Number:
Company Accounting Period:	From: To:

#	Director Name	Director Position / Department
1

Company Website URL:
Registered Address:
Is your trading address different from the above?
Trading address:

5.Firm Trading and Share Structure Details

Is your company part of a group or does it have any links with any other businesses?

#	Company Name:	Registration Number:
1

Please detail the share structure of the firm:

#	Name of Shareholder	Shareholding	Share Type
1

6.Firm Financial Details

Please describe how your business earns its revenues:

Total budgeted income for the next 12 months:
Income from Crypto activities:
Income from other regulated activities:
Income from non-regulated activities:

7.Firm’s Assets and Liabilities

The assets and liabilities listed below should be that of the firm rather than any personal assets or liabilities. This section should only be completed by Limited Companies, LLP’s or Partnership firms.

Assets:

Freehold
Motor Vehicles
Office Equipment
Goodwill
Other
Total Assets:

Debtors
Investments
Cash in bank
Other (please specify)

Liabilities:

Trade Creditors
Bank Overdraft
Taxation Liability
Industry debt
Total Firm Liabilities:

Loans, HP and Charge Accounts
Mortgages and Secured loans
Other Outstanding Liabilities
Potential Indemnity Liability (If known)

8.Business Structure

Please provide an organisational chart of your firm detailing reporting and management lines between staff and department heads. Should your firm have close links with other supporting or linked businesses please explain their association.

Please provide a list of all the individuals associated with the development, marketing, management, control and issuing of your cryptoassets:

#	Name:	Job Title:	Role and Responsibilities:	Email Address:
1

9.Product & Market Details

Does your cryptoasset use DLT? If so, please describe the network of nodes.

Does your cryptoasset work on:

As a percentage of your overall existing client base, to what extent are they:

	Restricted Investors
	Certified Sophisticated Investors
	High Net Worth Investors
	Not Applicable

As a percentage, to what extent of your target client base are they:

	Restricted Investors
	Certified Sophisticated Investors
	High Net Worth Investors

What is the average net return for your existing clients?

In the past what have been your primary channels of client acquisition? Please provide estimate percentage.

	Social Media
	Traditional Media
	Pay per Click
	Client Referrals

Referred business.

Please be aware that ‘refer-a-friend’ marketing may no longer be incentivised, however, you may work with affiliates and market comparison sites under an approved agreement.

What percentage of your sales come from 3rd party referrals?

Please describe the types of third parties that you work with.

Do you have an agreement with these third parties?

If yes, please upload a template agreement: