Approved Persons - Application to conduct a Controlled Activity
Individual Questionnaire
Application to;
- conduct a controlled function and/or
- become a shareholder or controller of a regulated firm, and/or
- be registered as a statutory auditor.
Name of Applicant
Date Received
FSC Use Only / Data inputted by / Verified byRequested by :
Date: / Date Requested / Date Completed
Other Regulator(s) / No Yes
Referee(s) / No Yes
Previous Employer(s) / No Yes
Open Source checks / No Yes
Professional Bodies / No Yes
GFIU / No Yes
Other :
NOTE: All sections must be completed on a "stand-alone" basis which can be supplemented by (but not replaced with) cross references to additional documents. In these cases, the relevant document, page and paragraph number should be clearly indicated in the appropriate section of the form.
Date of Revision: 1 Dec2014Personal Details
1.1 Personal details
TitleFirst names
Surname
Former Names or other names by which you are known by
(if any) / Date name change was effective
dd/mm/yy
dd/mm/yy
dd/mm/yy
dd/mm/yy
Date of Birth / dd/mm/yy
Country & Place of Birth
Nationality
Passport Number
Private Address
Email address
Other addresses in the past five years
Business Address
Business Tel No.
Business Fax No.
Business Web Address
Details of proposed appointment(s)
1.2 Details of proposed appointments
Enter details of all the controlled functions that the applicant is being proposed for each of the listed firms;
FirmDirector / Chief Executive Officer / Partner / Dir. of Unicorp. Assoc. / Trustee of Occup. Pension Scheme / EIF Director / Systems & Control Function / Appointed Actuary / Compliance Officer / MLRO / EEA Branch Oversight / Managerial Functions / Statutory Auditor
Details of shareholdings or control over a regulated entity’s voting rights
1.3 Details of influence over a regulated firm’s voting rights
Enter details of the influence over the voting rights over each regulated firm (including applicant firms) that the individual has influence over either directly or indirectly;
Held directly / Held indirectly / TotalFirm / Number of shares / Type of Share / % of Voting Rights / Number of shares / Type of Share / % of Voting Rights / % of Voting Rights
% / % / %
% / % / %
% / % / %
% / % / %
% / % / %
% / % / %
% / % / %
% / % / %
% / % / %
Experience & Qualifications
1.4 Please provide details of your employment history over the last ten years, starting with your most recent employment.
Please provide an explanation if there are any gaps in your employment during this period.;
Date from/to / Firm’s Name and Address / Nature of Business / Position held, key responsibilitiesreason for leavingdd/mm/yy to dd/mm/yy
dd/mm/yy to dd/mm/yy
dd/mm/yy to dd/mm/yy
dd/mm/yy to dd/mm/yy
dd/mm/yy to dd/mm/yy
dd/mm/yy to dd/mm/yy
dd/mm/yy to dd/mm/yy
dd/mm/yy to dd/mm/yy
1.5 Please provide details of any relevant professional or business qualifications and/or memberships of any professional bodies, exchanges or associations obtained or applied for, and the date on which those qualifications were obtained.
List also the name and date of any other relevant training.
1.6 Please provide full details of relevant experience and knowledge which directly supports your application for the positions that your are seeking approval for.
1.7 State whether you are, or have been, in a notifiable position with any other regulator outside of Gibraltar?
NoGo to section 2.1
YesPlease give details below and include the name(s) of the firm(s), the jurisdiction(s) and position(s) held as well as dates.
Good Reputation & Character
2.1 The following questions should be answered by entering a tick in the appropriate box.
In any case where a tick is entered in the YES box, full details should be given in a continuation sheet and attached to this form. For the purposes of questions 2.1.9, 2.1.11, 2.1.16, 2.1.17 and 2.1.22 the words financial services business are used to refer to investment services, fiduciary services, insurance, controlled activities, banking and auditing.
Please note that no time restriction applies to the matters you are asked to disclose. Any convictions and other relevant facts must be stated.
2.1.1 / Have you been convicted of any offence involving fraud or other dishonesty (whether or not in Gibraltar) under legislation relating to companies, building societies, credit unions, friendly societies, insurance, banking, auditing or other financial services, insolvency, consumer credit or consumer protection? / NoYes2.1.2 / Have you been convicted of any other offences (excluding minor motoring offences[1] ) other than any declared in 2.1.1 above or been subject to penalties for deliberate tax evasion? / NoYes
2.1.3 / Are you currently engaged in, or the subject of, any criminal or civil proceedings or arbitration (other than as an expert witness) or is any unsatisfied judgement debt or award outstanding against you? / NoYes
2.1.4 / Have you ever, in Gibraltar or elsewhere, been declared bankrupt or had your estate sequestrated, or entered into any compromise with creditors, or are you currently the subject of bankruptcy proceedings or proceedings for the sequestration of your estate? Are you aware of any such proceedings pending? / NoYes
2.1.5 / Have you ever entered into a deed of arrangement (or the equivalent) in favour of your creditors, or other composition or arrangement with creditors, or failed to satisfy a judgement debt under a Court Order made in Gibraltar or elsewhere within one year of the making of the Order? / NoYes
2.1.6 / Have you given personally any guarantees in respect of your firm’s liabilities or those of any firm or individual? / NoYes
2.1.7 / Have you ever been refused or had revoked any licence or authorisation under the following:
2.1.7.1 / Financial Services (Banking) Act. / NoYes
2.1.7.2 / Insurance Companies Act 1987 / NoYes
2.1.7.3 / Financial Services (Investment & Fiduciary Services) Act and/or Financial Services Act 1998 (now repealed) and/or Financial Services (Markets in Financial Instruments) Act. / NoYes
2.1.7.4 / Financial Services (Collective Investment Schemes) Act 2005. / NoYes
2.1.7.5 / Financial Services (Auditors) Act 2009. / NoYes
2.1.8 / Have you ever been refused or had withdrawn any authorisation to carry on investment, banking, insurance or auditing business in a territory other than Gibraltar? / NoYes
2.1.9 / Have you or, to your knowledge, your employer ever been refused or had revoked an authorisation or licence to carry on financial services business or auditing been disciplined by any regulatory body or professional body, whether in Gibraltar or otherwise? / NoYes
2.1.10 / Have you or, to your knowledge, your employer ever relinquished authorisation by such a body, or decided after making application, not to proceed with it? / NoYes
2.1.11 / Has any company or partnership of which you are, or have been, a controller, director or partner ever, to your knowledge, been refused or had revoked an authorisation or licence to carry on financial services business by any regulatory body or professional body, or been censured, disciplined, suspended, expelled, fined or been subject to any other disciplinary action by any such body? / NoYes
2.1.12 / Has any company or partnership of which you are, or have been, a controller, director or partner to your knowledge, ever relinquished authorisation by any body referred to in 2.1.11 above or decided not to proceed with an application to any such body after making one? / NoYes
2.1.13 / Have you or, to your knowledge, your employer been publicly censured or disciplined by any regulatory body, because of your or your employer’s business or professional activities? Are you or is your employer to your knowledge, currently undergoing any investigation or disciplinary procedure? / NoYes
2.1.14 / Have you ever been refused entry to any profession or vocation or been dismissed or requested to resign from any office or employment, or from any fiduciary office or position of trust, whether or not remunerated? / NoYes
2.1.15 / Have you ever been refused the right to carry on any trade, business or profession for which a specific licence, registration or other authority is required? / NoYes
2.1.16 / Have you ever knowingly been the subject of an investigation into allegations of misconduct or malpractice in connection with any financial services business or auditing? / NoYes
2.1.17 / Have you been the subject of a complaint about your conduct or advice in connection with financial services business or auditing in the last three years? / NoYes
2.1.18 / Have you ever resigned from a professional or regulatory body with a view to avoiding legal actions or disciplinary process? / NoYes
2.1.19 / Have you ever been disqualified by a court from acting as a director of a company, or from acting in the management or conduct of the affairs of any company, partnership or unincorporated association? / NoYes
2.1.20 / In the last ten years have you been the director of a company which has gone into liquidation or receivership, had an administrator or administrative receiver appointed or entered into any arrangements with its creditors either while you were a director or within three years of your ceasing to be a director? / NoYes
2.1.21 / Have you, in connection with the formation or management of any company, partnership or unincorporated association been adjudged by a court in Gibraltar or elsewhere civilly liable for any fraud, misfeasance, wrongful trading or other misconduct towards such a body or towards any members or creditors of such a body? / NoYes
2.1.22 / Have you ever been the subject of any civil action which has resulted in a finding against you by a court in respect of financial services business or auditing in Gibraltar or elsewhere or in respect of any matter other than the conduct of financial services business? / NoYes
2.1.23 / Have you ever been concerned with the management or conduct of affairs of any company which has been at any time during your involvement, investigated by an inspector appointed under the Companies Act, or required to produce books and papers to an inspector so appointed? / NoYes
2.1.24 / Have you ever been concerned with the management or conduct of affairs of any company or partnership which, by reason of any matter relating to a time when you were so concerned, has been convicted of any criminal offence in Gibraltar or elsewhere, censured, disciplined or publicly criticised, by an enquiry, or any governmental or statutory authority or any other regulatory body recognised by such authority, or by a similar body, which has resulted in a finding against the company by a court? / NoYes
2.1.25 / Have you ever been the subject of disciplinary proceedings by your current or former employer in relation to the conduct of financial services business? If so, please provide details of such disciplinary proceedings and of their outcome and of any subsequent action taken by your employer or former employer. / NoYes
Other Business Interests/Directorships
3.1 Do you have, or have had in the last 10 years, any other business interests?
NoGo to section 4
YesPlease answer 3.2
3.2 State whether these are or were;
3.2.1 Any bodies corporate (including a company in the group of which the applicant forms part of) of which you are or were a director?
NoGo to section 3.2.2
YesPlease fill in the rest of this section
Name / Principal Activities / Past or Current DirectorshipPastCurrent
PastCurrent
PastCurrent
PastCurrent
PastCurrent
PastCurrent
PastCurrent
If any of the above are connected to the applicant firm, that fact should be disclosed.
3.2.2 Any bodies corporate in which you have, or have had, a beneficially-owned interest in more than 50 per cent of the equity share capital, whether or not you are or were a director?
NoGo to section 3.2.3
YesPlease fill in the rest of this section
Name / Principal Activities / % Ownership%
%
%
%
%
%
%
3.2.3 State whether you have, or have had, any other business interests involving a possible personal liability, either as a sole trade or as a partner?
NoGo to section 4
YesPlease give details below
3.3Directors’ Declaration (to be completed only if appointed as a Director)
I understand that my appointment as a company director makes me subject to certain duties and liabilities arising under statute, regulations and common law (collectively, the ‘Duties’). I undertake to ensure that I am aware of these Duties prior to my appointment, and to keep my knowledge of these Duties up to date so long as they apply to me.
Good Reputation & Character
I further understand that my appointment as a company director makes me responsible for ensuring that the FSC is notified of any developments which may impact upon my good reputation and character.
In my Individual Questionnaire, I provided answers to questions stated in Section 2.1 above.
Should, at any time whilst exercising my duties and responsibilities as a company director, any response previously given to these questions change, I shall notify the FSC of such development through resubmission of the relevant question(s) and answer(s), providing additional details where necessary.
Dated / dd/mm/yySigned
Additional Information for applications as a Statutory Auditor
4.1 Please attach a copy of your professional body membership certificate.
Copy of your professional body membership attached.
If you have a copy of your professional body’s practising certificate entitling you to engage in public practice, please also attach it.
4.2 Will the applicant haveprofessional indemnity insurance before being authorised?
No Go to section 4.3
Yes
Please give details
Amount & CurrencyExcess
Name of Insurer
Expiry Date / dd/mm/yy
4.3 Are you approved as a Statutory Auditor in an EEA State?
No Go to section 4.7
YesPlease answer 4.4 – 4.6
4.4 Please provide details of the Competent Authority that has approved you as a Statutory Auditor.
4.5 Please state the date you were approved as a Statutory Auditor.
4.6 Please provide your Public Register number and/or other details of where this can be verified.
Go to section 5.1
4.7 Please provide details of a referee which the FSC can contact to confirm you have undertaken an examination relating to auditing within your qualifications.
TitleFull Name
Job Title/Business Name
Business address
Phone number
Fax number
Email address
4.8 Please provide details of a referee which the FSC can contact to confirm you have two or more years of local audit experience under a Statutory Auditor in Gibraltar.
Please note this referee must be an existing Statutory Auditor in Gibraltar.
TitleFull Name
Job Title/Business Name
Business address
Phone number
Fax number
Email address
References
5.1 May the FSC take up references from your previous employers in the last five years?
NoPlease explain why not?
YesPlease give details below of contact persons at your previous employers.
TitleFull Name
Job Title/Business Name
Business address
Phone number
Fax number
Email address
Title
Full Name
Job Title/Business Name
Business address
Phone number
Fax number
Email address
Warranty
I, (name of individual)
warrant:
(a)that I have truthfully and fully answered the relevant questions in this Questionnaire and disclosed any other information which might reasonably be considered relevant:
(b)that I will promptly notify the FSC of any changes in the information I have provided and supply any other relevant information which may come to light;
and
(c)that I fully understand and acknowledge that a failure on my part to comply with this warranty will render the application liable to be refused and, if such failure is discovered after the application has been accepted, will render the application liable to be terminated.
I hereby irrevocably consent to the disclosure by the FSC, in the performance of its functions under the law of Gibraltar, of any information concerning me that may come into its possession including, without limitation, disclosure of such information to the Applicant for authorisation mentioned above and disclosure in any of the circumstances which might be material to the FSC in making its determination.
I hereby authorise the FSC to take up such references and make such enquiries as are necessary to consider this questionnaire.
I understand that I may not engage or be appointed to the role for which I have sought authorisation, until such a time as I receive express, written authorisation from the FSC
Dated / dd/mm/yySigned
Position
Statement on Data Protection
The Financial Services Commission is exempted by Section 19 of the Data Protection Act 2004 (the “Act”) from many of the provisions of the Act which includes the Obligation to Register, Principles for data quality and security, information to be given to data subjects, data subject’s access and rectification of data (sections 24, 6, 10, 14 and 15 of the Act). However, to the maximum extent possible, the FSC will follow the obligations imposed by the Act unless it considers that compliance would be likely to prejudice the proper discharge of its functions or prejudice its purposes.
Data Controller
Financial Services Commission of PO Box 940, Suite3, Ground Floor, Atlantic Suites, Europort Avenue, Gibraltar.
Purposes for which data is collected and processed
The Financial Services Commission (FSC) is under a statutory obligation to ensure that those persons who exercise control or significant influence or control over the operations of a regulated financial firm be fit and proper as well as to ensure that they have the correct training and competency to conduct that activity. As such the FSC may conduct enquiries on such individuals for these purposes.
Recipients of data
In order to conduct this role, the Financial Services Commission may pass or be required to confirm some or all of the aspects of the data that you have provided with other regulators who perform similar roles to the FSC or law enforcement agencies within Gibraltar or in other jurisdictions.
Similarly, other regulators and law enforcement agencies may seek to confirm with the FSC details of data that you may have supplied to them.
Subject to the confidentiality provisions that the FSC, its officers and staff are subjected to under various regulatory Acts for which it has responsibilities and the restrictions imposed upon it by the Act, the FSC will share your data only for the purposes provided therein.
Your rights to access data held by the FSC on you.
Upon receipt of a written request and subject to being able to prove that the person making the request is the data subject, the FSC will confirm whether or not we hold personal data about you and if so, what this data is. This data will be provided to you in a readily understood format.
The fee for receiving this information is £10 and must be made in a form available from the FSC’s web-site at Alternatively, these forms are available from our reception at Suite 3, Ground Floor, Atlantic Suites, Europort Avenue, Gibraltar or one can be forwarded to you by calling (+350) 200 40283.
Your right to rectify data held by the FSC on you
If data held by the FSC on you is inaccurate or out of date you can require the FSC to update the data by making this request in writing.
Your right to complain about your treatment to the Gibraltar Data Protection Commissioner
If you consider that the FSC has not complied with the requirements of the Act you may make a complaint to the Data Protection Commissioner:
Gibraltar Data Protection Commissioner
Gibraltar Regulatory Authority
Suite 811, Europort
Gibraltar
Tel +350 200 74636
Fax +350 200 72166
Human Rights
Irrespective of anything contained in this statement, your rights under the European Convention on Human Rights and the Gibraltar Constitution Order remain unfettered.
1
[1] Minor motoring offences covers only those offences that do not potentially carry a custodial sentence.