Please only complete this form if you have been requested to do so by your firm or Rockstone Compliance.

The information contained below will be publicly available, please confirm that you understand this

Yes

Name

First Name

Last Name

Preferred Title

Relevant Role Held

Principal Firm Name

Appointed Representative Firm Name

Leave blank if not working within an AR firm

Do you have an existing Individual Reference Number (IRN) with the FCA?

If you have previously worked as a mortgage adviser, the answer will be yes. You can check by entering your name here - https://register.fca.org.uk/s/

Yes

If yes, what is your Individual Reference Number (IRN?)

This detail is shown on the FCA register under your name - i.e ABC123456 Please do not confuse with a Firm Reference Number which is a 6 reference number and relates to firms only. Your personal IRN will start with your initials letter, followed by 6 numbers.

Type of business the Directory Person is qualified to undertake

Mortgage Advice - CeMAP 1, 2 and 3 held

Equity Release Advice - CeRER held

N/A - Full qualification not held

Which Industry Accreditation to you hold?

LIBF

CII

Other (please specify below)

Full Address of Workplace (Head Office / Trading Address)

Please do not use your home address.

The information below will NOT be publicly available

National Insurance Number

Date of Birth DD/MM/YY

Passport Number

Only to be provided if NINO is not available

Nationality

Only to be provided if NINO is not available

Declaration

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). The FCA will not verify the information about Directory persons which is reported by the firm. If a firm becomes aware of any inaccuracies or errors in the information reported about a Directory person it must rectify that information as soon as possible in accordance with applicable data protection legislation. Rockstone Compliance will not send a notification when your profile goes live. However, you can check its status directly on the FCA register. Please note that updates to applications may take up to 72 hours.

Are you happy for your profile to go live on the FCA register immediately*?

*within the next 72 hours.

Yes

If no, please add a date that you wish the register to be updated

Leave blank if not applicable.

YYYY

Review and Confirmation

I agree that the information I have provided above is accurate and complete

Yes

Please confirm that you have read and understood the declaration

Yes

Name

First Name

Last Name

Date

YYYY

Please provide further information here if required

Thank you for completing the ‘Certification Regime Data Collection’ form.

If you have any questions about any of the content, or have any documentation to share. Please contact Elizabeth on 0333 444 3103 or via email elizabeth.harris@rockstonecompliance.co.uk

Certification Regime Data Collection Form

Rockstone Compliance