APPLICATION FORMS AND NOTICES (AFN) – AUT - CON

For DFSA use only

Form AUT – CON

Applications and notifications

concerning a change in control

Name of Authorised Firm
DFSA Reference Number
Firms are requested to contact theSupervision Department of the DFSA
(+9714 3621500) before considering completing this application.

Purpose of this form

This form must be submitted by an Authorised Firm applying for approval or notifying the DFSA concerning a change in control of the Authorised Firm, this form may also be used by a Controller.

Authorised Firms are required to complete a form for each application or notification.

An Authorised Firm or Controller must submit an application or notification. As applicable, concerning a change in control, at least 28 days in advance of the proposed change, or immediately upon becoming aware of a proposed or actual change in control.

Contents

Section / Title
1 / Controllers (Individuals)
2 / Controllers (Undertakings)
3 / Details of new controls or change in level of control
4 / Additional information
5 / Declaration

Notes for completing this form

  • Defined terms are identified throughout this application form by the capitalisation of the initial letter of a word or phrase and are defined in the Glossary module (GLO) of the DFSA’s Rulebook.
  • Section 1 must be completed if the application/notification of a change in control relates to an individual.
  • Section 2 must be completed if the application/notification relates to an Undertaking.
  • Section 3 and 5 must be completed in respect of all applications/notifications.
  • Please use Section 4 if you wish to provide additional information that may clarify or support your answers in Sections 1-3.
  • Questions must be answered fully and the use of abbreviations or acronyms should be avoided or defined.
  • Answers must be typed in electronic format and the form must be signed by the Authorised Firm’s Senior Executive Officer, Compliance Officer or relevant Controller. Versions of this form on the DFSA’s website are in PDF format. Editable Microsoft Word versions can be obtained from the DFSA.

SECTION 1 – CONTROLLERS (INDIVIDUALS)

Note: Please only complete this section if the application/notification relates to an individual

1.1 / Title (Mr, Mrs etc.)
1.2 / Family name
1.3 / Other names
1.4 / Residential address
1.5 / Date of birth
(DD/MM/YYYY)
1.6 / Place of birth
1.7 / Passport(s) number(s)
Note: Please provide a copy of the passport
1.8 / Nationality
1.9 / Please provide details of any Directorships or Partnerships held
Company/Partnership name / Principal activity
1.10 / Details of any other Controller positions held
Company/Partnership name / Principal activity / Nature of control

SECTION 2 - CONTROLLERS (UNDERTAKINGS)

2.1 / Full name of Undertaking
2.2 / Date of formation/establishment
(dd/mm/yyyy)
2.3 / Place of establishment
2.4 / Contact address
2.5 / Head office address
(if different from 2.4)
2.6 / Undertakings website address
(If applicable)
2.7 / Legal status
(Company/Partnership/trust)
2.8 / Principal activity
2.9 / Name of the Undertaking’s Financial Services Regulator
(If applicable)
2.10 / Directors/Partners of the Controller
Full name / Job title / Date of birth
(dd/mm/yyyy)

Please use additional sheets as necessary.
SECTION 3 – DETAILS OF NEW CONTROL OR CHANGE IN LEVEL OF CONTROL

3.1 / Is the Authorised Firm seeking approval or making a notification under the Rules?
3.1.1 / Approval
3.1.2 / Notification
3.2 / State the reason for approval/notification
3.2.1 / Holding increase from below 10% to more than 10%;
3.2.2 / Holding increase from below 30% to 30% or more;
3.2.3 / Holding increase from below 50% to 50%or more;
3.2.4 / Holding decrease from more than 50% to 50% or less;
3.2.5 / Significant management influence
3.3 / Effective date (dd/mm/yyyy)
3.4 / Total control expressed as a percentage of shares
(as defined in GEN 11.8.3)
3.5 / Please provide details of how the control can be exercised

SECTION 4 - ADDITIONAL INFORMATION

Please comment on the following specific matters:

  • Background of the new Controller
  • Reason for the change of control
  • Impact of the new Controller on the Authorised Firm and/or its group
  • Timetable of the proposed or actual change
  • Revised Structure (pre and post change, or attach aseparate diagram)
  • Updated (if applicable) contact details of the Home State Regulator of the new controller (see separate section below)
  • Any other matter that may be relevant

If applicable, name and country of controller’s Financial Services Regulator
Name of contact or supervisor at the above Financial Services Regulator
Telephone, fax or email of the above contact or supervisor

SECTION 5 - DECLARATIONS

Declaration by the Authorised Firm

  1. I declare that, to the best of my knowledge and belief, having made due enquiry, the information given in this form is complete and correct. I understand that it is an offence under Article 66 of the Regulatory Law 2004 to provide to the DFSA any information which is false, misleading or deceptive or to conceal information where the concealment of such information is likely to mislead or deceive the DFSA.
  1. I declare my understanding that the DFSA may request more detailed information (including but not limited personal, educational, employment and financial information) should it be deemed necessary to adequately assess the Controller. I consent to the DFSA contacting any previous employers, educational institutions, professional organisations or any other organisation, to verify any information contained in this form.
  1. I confirm that I have the authority to declare as specified above and to sign this form. I also confirm that I have the authority to give the consent specified above.

4.For the purposes of complying with DIFC Data Protection Law 2007, I understand that any Personal Data provided to the DFSA will be used to discharge its regulatory functions under the Regulatory Law 2004 and other relevant legislation and may be disclosed to third parties for those purposes.

Signature of Senior Executive Officer, Compliance Officer or relevant Controller / Date
Name of Senior Executive Officer, Compliance Officer or relevant Controller

Please return the completed form to:

Dubai Financial Services Authority

Supervision Department

Level 13, The Gate

PO Box 75850

Dubai, UAE

Firms are advised to retain a copy of the form and all relevant attachments for their records.

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