Name *

First Name

Last Name

Job Title *

Senior Manager - SMF 3 / SMF 16

Mortgage / Insurance Adviser - Certified

Non Sales Personnel (Compliance / Administrator / Business Development etc )

Are you CeMAP or CeRER qualified? *

Yes

No

1a) Have you ever been convicted of any offences involving fraud, theft, false accounting, serious tax offences or other dishonesty or an offence (whether or not in the United Kingdom) relating to companies, building societies industrial and provident societies, credit unions, friendly societies, insurance banking or other financial services, insolvency consumer credit or consumer protections, money laundering, market manipulations or insider dealing? (Please note: spent convictions need not be disclosed, however, if your role requires FCA approval you will need to provide this information as part of the approval process) *

Yes

No

1b) Are you the subject of any current criminal proceedings? *

Yes

No

1c) Have you ever been given a caution in relation to any criminal offence? *

Yes

No

1d) Have you any convictions for any offences other than those listed in question 1 a) above which are not spent, whether or not in the United Kingdom (excluding traffic offences unless these resulted in a ban from driving or involved driving without insurance)? *

Yes

No

2. Have there been any negative changes to your financial profile in the last 12 months? *

Yes

No

Do you have any outstanding personal financial difficulties that could impact your role? *

Yes

No

What is your current Credit Score? *

You can check this via Experian or CheckMyFile for free.

Excellent

Good

Fair

Poor

Very Poor

Don't Know

2a) Are you or have you ever been the subject of any civil proceedings, arbitration or litigation, including proceedings that resulted in a County Court Judgment (CCJ) or other judgement debts, in the United Kingdom or elsewhere? *

Yes

No

2b) Are you aware of any intention to begin such proceedings against you in the future? *

Yes

No

2c) Do you have any judgement debts (including CCJs) made under a court order still outstanding, whether in full or in part? *

Yes

No

2d) Have you ever failed to satisfy any such judgement debts within one year of making of the order? *

Yes

No

3a) Are you or have you ever been, the subject of any bankruptcy proceedings, or proceedings for the sequestration of your estate? *

Yes

No

3b) Have you ever entered into a deed of arrangement or an individual voluntary arrangement (or in Scotland a trust deed) or other agreement in favour of your creditors, or are you doing so? *

Yes

No

4) Have you ever been found guilty of conducting any unauthorised regulated activities or been investigated for possible conduct of unauthorised regulated activities? *

Yes

No

5) Are you, or have you ever been, the subject of an investigation into allegations of misconduct or malpractice in connection with any business activity? *

Yes

No

6a) Have you ever, either in the United Kingdom, or elsewhere- been refused entry to, or been dismissed or requested to resign from, any profession, vocation, office or employment, or from any fiduciary office or position of trust, whether or not remunerated? *

Yes

No

6b) Have you ever, either in the United Kingdom, or elsewhere – been refused, restricted in, or had suspended, the right to carry on any trade, business or profession for which specific licence, authorisation, registration, membership or other permission is required? *

Yes

No

6c) Have you ever, either in the United Kingdom, or elsewhere –been disqualified by a court from acting as a director of a company or from acting in a management capacity of conducting the affairs of any company, partnership or unincorporated association? *

Yes

No

6d) Have you ever, either in the United Kingdom, or elsewhere –been the subject of a disqualification direction under section 59 of the Financial Services Act 1986 of a prohibition order, under section 56 of the Financial Services and Markets Act 2000, or received a warning notice to make such a direction or order? *

Yes

No

7) Do you have any outside employment? If yes, please provide full details in Supplementary Notes below. *

Yes

No

7b) Are you aware of any conflicts of interest that could impact your duties in your role? *

Yes

No

8) Have you ever been a controller, director, senior manager, and partner or company secretary of a company, partnership, or unincorporated association? *

Yes

No

9a) In respect of activities regulated by the FCA have you, or any company, partnership or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, during your association with that entity and for a period of three years after you ceased to be associated with it, ever – been refused, had revoked, restricted or terminated any licence, authorisation, registration, notification, membership or other permission granted by any such body? *

Yes

No

9b) In respect of activities regulated by the FCA have you, or any company, partnership or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, during your association with that entity and for a period of three years after you ceased to be associated with it, ever – been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action by any such body? *

Yes

No

9c) In respect of activities regulated by the FCA have you, or any company, partnership or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, during your association with that entity and for a period of three years after you ceased to be associated with it, ever –resigned whilst under investigation by, or been required to resign from, any such body? *

Yes

No

9d) In respect of activities regulated by the FCA have you, or any company, partnership or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, during your association with that entity and for a period of three years after you ceased to be associated with it, ever – been the subject of any civil action which has resulted in a finding against you or it by a court? *

Yes

No

10a) Has any company, partnership or unincorporated association for which you 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

10b) Has any company, partnership or unincorporated association for which you 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 declared by a court liable for any fraud, misfeasance, wrongful trading or other misconduct? *

Yes

No

10c) Has any company, partnership or unincorporated association for which you 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 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? *

Yes

No

10d) Has any company, partnership or unincorporated association for which you 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 convicted of any criminal offence, censured, disciplined or publicly criticised, by any inquiry, by the Takeover Panel of any other governmental or statutory authority or any other regulatory body? *

Yes

No

11) Have you ever been removed from a lender or providers panel? If yes, please detail name of the Lender, the date and circumstances. *

Yes

No

11a) Have you ever been refused registration from a lender or providers panel? If yes, please detail the name of the lender or provider, the date and circumstances. *

Yes

No

13) Have you adhered to the firm’s compliance policies, including reporting any concerns or breaches? *

Yes

No

14) Have you maintained the knowledge and skills necessary for your role ? *

Yes

No

15) Have you complied with all regulatory requirements, including those relating to anti-money laundering (AML) and the prevention of financial crime? *

Yes

No

16) Have you been subject to any regulatory or compliance breaches in the past 12 months? *

Yes

No

I hereby certify that the information supplied to Rockstone Compliance is, to the best of my knowledge and belief, accurate in all material respects and does not omit any information relating to me which might reasonably be considered relevant to my role. Furthermore, I hereby undertake and agree that I shall immediately notify my employer of any changes in the information provided in this form which occur after the date of submission of this review. *

Yes

Date

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