Industry Member Enrollment

Licensed money transmitters, payment card issuers and distributors, payment processors, international remittance companies, bill payment companies, mobile payment application providers, payment aggregators, virtual currency exchanges and administrators, eWallet providers.

Principal Office Address

Address

City

State

Postal Code

Licensing Information

Registered as an MSB with the FinCEN / Dept of Treasury?

Yes

Licensed as a money transmitter in any US States?

Yes

If so, how many states?

Doing business in what countries?

Company Contacts

Primary Contact

First Name

Last Name

Phone

Title

Seconary Contact

First Name

Last Name

Phone

Title

Approval

The above named company hereby registers as an Industry Member of the Money Services Business Association (MSBA). We agree to participate in MSBA activities, comply with MSBA rules, and support the goals of the MSBA, in accordance with applicable laws.

I accept the terms above and testify to the accuracy of the information provided above.

Full Name

Serves as a digital signature.

An invoice with payment instructions will be sent after review of enrollment form.