Has the candidate previously been approved by the FCA / PRA? *

Yes

No

Name *

First Name

Last Name

Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

1.1.1 a) Have you ever been convicted of any criminal offence (whether spent or not and whether or not in the United Kingdom): *

Involving fraud, theft, false accounting, offences, against the administration of public justice (such as perjury, perverting the course of justice and intimidating of witnesses or jurors), serious tax offences or other dishonesty, or

Relating to companies, building societies, industrial and provident societies, credit unions, friendly societies, insurance, banking or other financial services, insolvency, consumer credit or consumer protection, money laundering, market manipulations or insider dealing?

None of the above

b) Are you currently, or have you ever been, the subject of any criminal proceeding, whether in the UK or elsewhere? *

Yes

No

c) Have you ever been given a caution in relation to any criminal offence? *

Yes

No

1.1.2 Have you had any convictions for any offences other than those in 1.1.1 above (excluding traffic offences that did not result in a ban from driving or did not involve driving without insurance?) *

Yes

No

1.1.3 Are you the subject of any ongoing criminal investigation? *

Yes

No

1.1.4 Have you ever been ordered to produce documents pursuant to any criminal investigation or been the subject of a search (with or without a warrant) pursuant to any criminal investigation? *

Yes

No

1.1.5 Has any firm at which you hold or have held a position of influence ever: *

a) Been convicted of any criminal offence? (Please check the guidance notes for the meaning of 'position of influence' in the context of the questions in this part of the form).

b) Been summonsed, charged with or otherwise investigated or prosecuted for any criminal offence?

c) Been the subject of any criminal proceeding which has not resulted in a conviction?

d) Been ordered to produce documents in relation to any criminal investigation or been the subject of a search (with or without a warrant) in a relation to any criminal investigation?

d) None of the above

1.2.1 Have you ever been the subject of a judgement debt or award against you? *

Yes

No

1.2.2 Have you ever been party to any civil proceedings which resulted in any order against you (other than a judgement debt or award referred to at 1.2.1 above)? (You should include, for example, injunctions and employment tribunal proceedings.) *

Yes

No

1.2.3 Are you aware of: *

a) Any proceedings that have begun, or anyone's intention to begin proceedings against you, for a CCJ or another judgment debt?

b) More than one set of proceedings, or anyone's intention to begin more than one set of proceedings, that may lead to a CCJ or other judgment debt?

c) Anybody's intention to claim more than £1,000 of CCJs or judgment debts in total from you?

d) None of the above

1.2.4 Do you have any current judgment debts (including CCJs) made under a court order still outstanding, whether in full or in part? *

Yes

No

1.2.5 Have you ever failed to satisfy any judgment debts (including CCJs) made under a court order still outstanding, whether in full or part, within one year of the order being made? *

Yes

No

1.2.6 Have you ever: *

a) Filed for your own bankruptcy or had a bankruptcy petition served on you?

b) Been adjudged bankrupt?

c) Been the subject of a bankruptcy restrictions order (including an interim bankruptcy restrictions order) or offered a bankruptcy restrictions undertaking?

d) Made any arrangements with your creditors, for example a deed of arrangement or an individual voluntary arrangement (or in Scotland a trust deed)?

e) Had assets sequestrated?

f) Been involved in any proceedings relating to the above matters even if such proceedings did not result in the making of any kind of order against you or result in any kind of agreement with you?

g) None of the above

1.2.7 Do you, or any undertaking under your management, have any outstanding financial obligations arising from regulated activities, which have been carried out in the past? (whether or not in the UK or overseas)? *

Yes

No

1.2.8 Have you ever been adjudged by a court or tribunal (whether criminal, civil or administrative) for any fraud, misfeasance, negligence, wrongful trading or other misconduct? *

Yes

No

1.2.9 Are you currently: *

a) Party to any civil proceedings? (Including those covered in 1.2.7)

b) Aware of anybody's intention to begin civil proceedings against you? (You should include any ongoing disputes whether or not such dispute is likely to result in any order against you.)

C) None of the above

1.2.10 Has any firm at which you hold or have held a position of influence ever been: *

a) Adjudged by a court civilly liable for any fraud, misfeasance, wrongful trading or other misconduct?

b) The subject of a judgment debt or award against the firm? (You should include all CCJs) made against the firm, whether satisfied or not.

c) Party to any other civil proceedings which resulted in an order against the firm other than in relation to matters covered in 1.2.10 a) and 1.2.10 b) above?

d) None of the above

1.2.11 Is any firm at which you currently hold, or have held within the last 12 months from the date of submission of this form, a position of influence: *

a) a party to civil proceedings?

b) Aware of anyone's intention to begin civil proceedings against them?

c) None of the above

1.2.12 Has any company, partnership, or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, in the United Kingdom or elsewhere, at any time during your involvement, or within one year of such an involvement, been put into liquidation, wound up, ceased trading, had a receiver or administrator appointed or entered into any voluntary arrangement with its creditors? *

Yes

No

1.3.1 Have you ever been: *

a) Disqualified from acting as a director or similar position? (One where the candidate acts in a management capacity or conducts the affairs of any company, partnership or unincorporated association).

b) The subject of any proceedings of a disciplinary nature (whether or not the proceedings resulted in any finding against you)?

c) The subject of any investigation which has led or might lead to disciplinary proceedings?

d) Notified of any potential proceedings of a disciplinary nature against you?

e) The subject of an investigation into allegations of misconduct or malpractice in connection with any business activity?

(This question covers internal investigation by an authorised firm, as well as investigation by a regulatory body, at any time).

f) None of the above

1.3.2 Have you ever been refused entry to, or been dismissed, suspended or requested to resign from, any professional, vocation, office or employment, or from any fiduciary office or position of trust whether or not remunerated? *

Yes

No

1.3.3 Do you have any material written complaints made against you by your clients or former clients in the last five years which you have accepted, or which are awaiting determination, or have been upheld - by an ombudsman or complaints scheme? *

Yes

No

1.4.1 In relation to activities regulated by the FCA and/or PRA or any other regulatory body (see note section 5), has: • You, or • Any company, partnership or unincorporated associate of which the candidate is or has been a controller, director, senior manager, partner or company secretary, during the candidate's association with the entity and for a period of three years after the candidate ceased to be associated with it, ever - *

a) Been refused, had revoked, restricted, been suspended from or terminated, any licence, authorisation, registration, notification, membership or any other permission granted by any such body?

b) Been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or interventional action by any such body?

c) Received a warning (whether public or private) that such disciplinary or interventional action may be taken against you or the firm?

d) Been the subject of an investigation by any regulatory body, whether or not such an investigation resulted in a finding against you or the firm?

e) Been required or requested to produce documents or any other information to any regulatory body in connection with such an investigation (whether against the firm or otherwise)?

f) Been investigated or been involved in an investigation by an inspector appointed under companies or any other legislation, or required to produce documents to the secretary of state, or any other authority, under any such legislation?

g) Ceased operating or resigned whilst under investigation by any such body or been required to cease operating or resign by any regulatory body?

h) Decided, after making an application for any licence, authorisation, registration, notification, membership or any permission granted by any such body, not to proceed with it?

i) Been the subject of any civil action relation to any regulated activity which has resulted in a finding by a court?

j) Provided payment services or distributed or redeemed e-money on behalf of a regulated firm or itself under any contractual agreement where that agreement was terminated by the regulated firm?

k) Been convicted of any criminal offence, censured, disciplined, or publicly criticised, by any inquiry, by the Takeover Panel or any governmental or statutory authority or any other regulatory body (other than as indicated in this group of questions)

l) None of the above

1.4.2 In relation to activities regulated by the FCA/PRA or any other regulatory body, have you or any firm at which you hold or have held a position of influence at any time during and within one year of your association with the firm ever: *

a) Been found to have carried on activities for which authorisation or registration by the FCA/PRA or any other regulatory body is required without the requisite authorisation?

b) Been investigated for the possible carrying on of activities requiring authorisation or registration by the FCA/PRA or any other regulatory body without the requisite authorisation whether or not such investigation resulted in a finding against you?

c) Been found to have performed a controlled function (or an equivalent function requiring approval by the FCA/PRA or any other regulatory body) without the requisite approval?

d) Been investigated for the possible performance of a controlled function (or an equivalent function requiring approval by the FCA/PRA or any other regulatory body) without the requisite approval, whether or not such investigation resulted in a finding against you?

e) Been found to have failed to comply with an obligation under the Electronic Money Regulations 2011 or Payment Services Regulations 2009 to notify the FCA/PRA of the identity of a person acting in a position of influence over its electronic money or payment services business?

f) Been the subject of disqualification direction under section 59 of the Financial Services Act 1986 or a prohibition order under section 56 FSMA, or received a warning notice proposing that such a direction or order be made, or received a private warning?

g) None of the above

1.5.1 Are you, in the role to which the application relates, aware of any business interests, employment obligations, or any other circumstance which may conflict with the performance of the controlled functions for which approval is now being sought/ in the respect of your control of the firm / with your role as controller of the applicant firm or your position at the controller?

Yes

No

1.5.3 Are you aware of any other information relevant to this notification that we might reasonably expect you to give? *

Yes

No

Declaration of Candidate It is a criminal offence, knowingly or recklessly, to give the FCA and/or PRA information that is materially false, misleading or deceptive (see sections 398 and 400 Financial Services and Markets Act 2000). Even if you believe or know that information has been provided to the FCA and/or PRA before (whether as part of another application or otherwise) or is in the public domain, you must nonetheless disclose it clearly and fully in this form and as part of this application – you should not assume that the FCA and/or PRA will itself identify such information during the assessment of this application. There will be a delay in processing the application if information is inaccurate or incomplete, and it may call into question the suitability of the candidate and/or lead to the FCA and/or PRA exercising their powers (including but not limited to taking disciplinary/ Enforcement action). You must notify the FCA and/or PRA immediately if there is a change to the information in this form and/or if inaccurate information has been provided (insofar as the FCA and/or PRA are reasonably likely to consider the information material). The candidate confirms that the information provided in this application is accurate and complete to the best of his/her knowledge and that he or she has read the notes to this form. The candidate will notify the FCA and/or PRA immediately if there is a material change to the information provided. The candidate confirms that the attached Statement of Responsibilities / Scope of Responsibilities (as relevant) accurately reflects the aspects of the affairs of the firm which it is intended that the candidate will be responsible for managing. The candidate confirms that they have accepted all the responsibilities set out in this Statement of Responsibilities / Scope of Responsibilities (as relevant) The candidate authorises the FCA and/or PRA to make such enquiries and seek such further information as it thinks appropriate to identify and verify information that it considers relevant to the assessment of this application. The candidate acknowledges and agrees that these checks may include credit reference checks or information pertaining to fitness and propriety, and is aware that the results of these enquiries may be disclosed to the employer/Applicant. Where applicable, the candidate agrees that he or she may be required to apply for a search to be made as to whether any criminal records are held in relation to him or her and to obtain a certificate (where such certificate can be obtained) and to disclose the result of that search to the firm submitting this application. The candidate agrees that the FCA and/or PRA may use the address specified for the candidate in this form as the proper address for service in the United Kingdom (as defined in the Financial Services and Markets Act 2000 (Service of Notice) Regulations (SI 2001/1420)) to serve any notices on the candidate. For the purposes of complying with the Data Protection Act 1998, the personal information provided in this form will be used by the FCA and PRA to discharge their statutory functions under the Financial Services and Markets Act 2000 and other relevant legislation, and will not be disclosed for any other purpose without the permission of the candidate. The candidate confirms that he or she understands the regulatory responsibilities of the proposed role as set out in the rules of conduct in the FCA’s COCON and/or the following Parts in the PRA Rulebook (as applicable): Conduct Rules, Insurance – Conduct Standards, Non-Solvency II Firms – Conduct Standards, and Large Non-Solvency II Firms – Conduct Standards. The candidate is aware that, while advice may be sought from a third party (e.g. legal advice), responsibility for the accuracy of information, as well as the disclosure of relevant information, on the form is ultimately the responsibility of those who sign the application. In addition to other regulatory responsibilities, firms, and approved persons have a responsibility to disclose to the FCA and/or PRA matters of which it would reasonably expect to be notified. Failure to notify the FCA and/or PRA of such information may lead to the FCA and/or PRA taking disciplinary or other action against the Applicant and/or the candidate *

Yes

I confirm the typed name above should be taken as my signature. *

Yes