DIR1.1
DIRECTOR/SENIOR MANAGER
STATUTORY DECLARATION FORM
Personal details
1. Name:
2. Date of birth:
3. Email address:
4. Home address:
Street number
Street name
Suburb
Town or city Postcode
5. Daytime te
lephone number:
6.
Applicant’s name:
7.
Applicant’s Financial Service Provider number:
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Date:
_______/_______/_______
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DIR1.1
Professional history
For each
question answer Yes or No. If Yes, attach a document outlining the details requested.
8. Have you been the subject of any disciplinary action taken by a disciplinary body for
any profession or occupation in New Zealand or overseas?
Yes No
If Yes, d
escribe when and why the disciplinary action was taken, details of the disciplinary body
that took the disciplinary action and what the outcome was.
9. Have yo
u within the last 7 years:
been a director of, or
been a partner in, or
held any position of senior management in
any company that has go
ne into liquidation or receivership while you were connected to that
organisation.
Yes No
If Yes, pro
vide the details of the company, your association with the company and the
circumstances surrounding the liquidation or receivership.
10.
Have you been dismissed, or subject to disciplinary proceedings resulting in a written warning,
for
a position of trust, fiduciary appointment or similar position in New Zealand or overseas?
Yes No
If Yes, provide the details of the position, including
when it was held, and the reason why you were
di
smissed
or what the circumstances were or the written warning.
11.
Have you ever been refused registration, or entrance, or barred from the right to carry on any
p
rofession or occupation that is relevant to the role of a director or senior manager in New
Zealand or overseas?
Yes No
If Yes, pr
ovide details of the profession or occupation you were restricted entry into, including
details of the profession or occupation, and the reasons for the refusal.
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Date:
_______/_______/_______
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DIR1.1
12.
Are you currently a member of any professional bodies? Please see regulation 5(1) of the Financial
Markets Supervisors Regulations 2014 for examples of relevant professional bodies.
Yes No
If Yes,
provide details of all relevant professional memberships.
Character assessment:
13.
Have you ever been the subject of a successful civil or criminal proceeding, regulatory action,
or disciplinary action in New Zealand or overseas?
Yes No
If Yes, please provide (on a separate page) details of the matter, including what the finding was,
when the matter occurred and what the outcome of the finding was (i.e., a fine, censure,
warning or, a sentence of imprisonment).
Statutory declaration
I, _______________ _______________ _______________, of __________________________________________
solemnly and sincerely declare the following:
that I am the above named director / senior manager
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Date:
_______/_______/_______
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DIR1.1
that the information provided in this form is full and correct
that I understand the applicant’s obligations under the Financial Markets Supervisors Act 2011 and the
Financial Markets Supervisors Regulations 2014
I am aware the information provided in this form is being collected for the FMA. In
submitting (or authorising this form to be submitted), I authorise:
i. the FMA to collect personal information from any person, including any New Zealand or
overseas government agency or professional body, (a third party’) to determine my good
character as a senior manager or director of the applicant, including carrying out identity,
good character, qualification, and criminal checks
the FMA to disclose personal information to the third party
the third party to disclose personal information to the FMA
iv. the FMA to use personal information provided in, or collected in connection with, this
licensing application in performing its functions and exercising its powers under the Financial
Markets Supervisors Act 2011 or any other legislation.
And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and
Declarations Act 1957.
Signature of person making declaration
Declared at this day of 20
before me:
Full name an
d designation of person to take statutory declaration
(Note: If you are making this declaration outside of New Zealand, please ensure it is sworn in accordance with
section 11 of the Oaths and Declarations Act 1957).
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Date:
_______/_______/_______
Please initial here
ii.
iii.
DIR1.1
Checklist
Please confirm that you have attached/ included the following (please tick where applicable):
Your Curriculum Vitae
An explanatory statement, if required for one or more of questions 8 to 13
- Page 5 of 5 -
Date:
_______/_______/_______
Please initial here
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