FMA Declaration DA1.1 DIRECTOR / SENIOR MANAGER (of Applicant) V1.1
Page 2 of 4
My declaration for the ‘good character’ assessment
• 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
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
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
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
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
Are you aware of any other matters that may have an adverse impact on our view of your
character?
YES NO
