FMA Declaration DA1.1 DIRECTOR / SENIOR MANAGER (of Applicant) V1.1
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Applicant to provide personalised digital advice under the Financial Advisers (Personalised
Digital Advice) Exemption Notice 2018
Applicant name
Applicant FSP number
Director or senior manager to be completed by person making the declaration
Personal details
Gender tick one
Male Female
Date of birth / /
DD MM YYYY
Your name
First name
Middle name(s)
Last name
Other names you are,
or have ever been
known as e.g. maiden
names, aliases
First name
Middle name(s)
Last name
Contact email and
daytime phone
Business email
Landline/mobileinclude area
code
Residential details
Street number and name
Suburb
Town or city
Postcode
Position
tick one I am a director of the Applicant
I am a senior manager with responsibility for the Applicant’s digital advice
service
Senior managers only:
I have provided:
a position description wi
th details about my senior manager’s role in Appendix 2
DA1.1 Declaration
by director or senior manager
of applicant
FMA Declaration DA1.1 DIRECTOR / SENIOR MANAGER (of Applicant) V1.1
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My declaration for the ‘good characterassessment
Please select YES or NO for each question. If any answer is YES, you must provide full details in Appendix 1.
You must answer each question in relation to both New Zealand and/or other jurisdictions.
Nothing in this form affects your rights under the Criminal Records (Clean Slate) Act 2004.
1.
Have you ever been charged with or convicted of (in New Zealand or overseas) a criminal
offence relating to dishonesty, fraud, or misleading or deceptive conduct?
YES NO
2.
Have you ever been convicted (in New Zealand or overseas) of any offence that you were
sentenced to, or were liable to be sentenced to, a term of imprisonment for (even if you
were not imprisoned)?
YES NO
3.
Have you ever been charged with or convicted of an offence, or subject to a proceeding:
a. In New Zealand under any financial markets legislation, as defined in the
Financial Markets Authority Act 2011?
b. In another jurisdiction under any financial markets legislation equivalent to that
referred to in ‘a’ above?
YES NO
4.
Have you ever been the subject of any civil proceedings (in New Zealand or overseas) for
conduct relating to dishonesty, fraud, or misleading or deceptive conduct?
YES NO
5.
Have you ever been the subject of any proceedings or action taken by a regulatory
authority in New Zealand, or overseas?
YES NO
6.
In the last 15 years have you been (in New Zealand or overseas) a trustee, director or
partner of, or held any position of senior management in, any company or other
incorporated or unincorporated entity which, while you were connected to that entity:
a. was placed into liquidation, administration, receivership or statutory
management (or any overseas equivalent status), or
b. entered into any compromise agreement, moratorium or other restructuring to
avoid liquidation, administration or receivership (or any overseas equivalent)?
YES NO
7.
Have you ever been banned (in New Zealand or overseas) from:
a. providing financial services, or
b. acting as director of a company or other incorporated body, or
c. being involved in the management of any class of incorporated or
unincorporated entity?
YES NO
8.
Have you ever been dismissed or asked to resign, or subject to disciplinary proceedings
resulting from, or in respect of, a position of trust, fiduciary appointment or similar (in
New Zealand or overseas)?
YES NO
9.
Have you ever been refused registration or other entry into, or restricted from the right
to carry on in, any profession or occupation under the law of the country, or under the
membership rules of any professional body at any time (in New Zealand or overseas)?
YES NO
10.
In the last 15 years have you been made bankrupt, entered into a compromise
agreement with creditors or been placed into statutory management (in New Zealand or
overseas)?
YES NO
11.
Are you subject to any pending proceedings or actions (in New Zealand or overseas) that
mean you would have to answer YES to any of the above questions if an adverse finding
is reached?
YES NO
12.
Are you aware of any other matters that may have an adverse impact on our view of your
character?
YES NO
FMA Declaration DA1.1 DIRECTOR / SENIOR MANAGER (of Applicant) V1.1
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Consent and declaration
Consent to disclosure of information
I understand the information provided in this form is being collected by the Financial Markets
Authority (FMA) in relation to an application to be included in the list of providers able to provide
personalised digital advice under the Financial Advisers (Personalised Digital Advice) Exemption Notice
2018.
In signing this declaration, I authorise the FMA to conduct enquiries and collect personal information
about me from any third party, including any person and any New Zealand or overseas government
agency, regulatory body or professional body for the purpose of determining I am a person of good
character to hold the position of director or senior manager of the Applicant’s business. This includes
carrying out identity, good character, and criminal record checks.
For that purpose I authorise:
The FMA to disclose my personal information to any third party
The third party to disclose my personal information to the FMA
The FMA to use my personal information, provided or collected in connection with the
Applicant’s application, when the FMA performs its functions and exercises its powers under the
Financial Advisers Act 2008, or any other legislation
The FMA to disclose any personal information provided or collected about me to the Applicant,
for the purposes of assessing the application, communicating the outcome of the assessment or
providing reasons for the FMA’s position on the application.
Declaration
I ________________________________________ of ____________________________________
Full name Town/city and country
Declare that:
1. I am a director / senior manager (delete one) of the Applicant.
2. The information provided in this form, and in the appendices attached to it, is true, correct and
complete.
Signature
Dated: __________________________ day of _________________________________ 20___
Applicant: please attach the signed form to your applicationand retain original on file. We may ask for this
later.
FMA Declaration DA1.1 DIRECTOR / SENIOR MANAGER (of Applicant) V1.1
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Please use these appendices to provide the background and position information requested (if applicable). Your
completed declaration, including appendices, should be provided and uploaded as one document.
Appendix 1: Disclosure for good characterassessment
If you said YES to any of the questions 1-12 please provide full details below next to the correct question number.
Q 1
Q 2
Q 3
Q 4
Q 5
Q 6
Q 7
Q 8
Q 9
Q 10
Q 11
Q 12
Appendix 2: Position description
What is your position title?
What position do you report to?
How many direct reports to your role?
What is the description of your role?
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