Fillable Personal details DIRECTOR/SENIOR MANAGER STATUTORY DECLARATION FORM (Financial Markets Authority New Zealand)

Fill Online, Printable, Fillable, Blank Personal details DIRECTOR/SENIOR MANAGER STATUTORY DECLARATION FORM (Financial Markets Authority New Zealand) Form

Use Fill to complete blank online FINANCIAL MARKETS AUTHORITY NEW ZEALAND pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Personal details DIRECTOR/SENIOR MANAGER STATUTORY DECLARATION FORM (Financial Markets Authority New Zealand)

On average this form takes 14 minutes to complete

The Personal details DIRECTOR/SENIOR MANAGER STATUTORY DECLARATION FORM (Financial Markets Authority New Zealand) form is 5 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 54 other fields

Country of origin: NEW-ZEALAND
File type: PDF

Use our library of forms to quickly fill and sign your Financial Markets Authority New Zealand forms online.

BROWSE FINANCIAL MARKETS AUTHORITY NEW ZEALAND FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DIR1.1Var
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. Dayti
me telephone number:
6. Applicant’s name:
7.
Applicant’s Financial Service Provider number:
- Page 1 of 5 -
Date:
_______/_______/_______
Please initial here
DIR1.1Var
Professional history:
For each qu
estion 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, describe when and why the disciplinary action was taken, the name of the disciplinary
body that took the action and what the outcome was.
9. Have you wit
hin 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 gone into liquidation or receivership while you were connected to that
organisation.
Yes No
If Yes, provi
de 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,
when in
a position of trust, fiduciary appointment or similar position whether 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 dismissed, or what the circumstances were or the written warning.
11.
Have you ever been refused registration, or entry into, or barred from the right to carry on any
profession or occupation that is relevant to the role of a director or senior manager whether in
New Zealand or overseas?
Yes No
If Yes, provide details of the profession or occupation you were barred from entering,
including details of the profession or occupation, and the reasons for the refusal.
- Page 2 of 5 -
Date:
_______/_______/_______
Please initial here
DIR1.1Var
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 whether 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 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
- Page 3 of 5 -
Date:
_______/_______/_______
Please initial here
•
DIR1.1Var
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
that 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
ii.
the FMA to disclose personal information to the third party
iii.
the third party to disclose personal information t
o the FMA
iv. the FMA to use personal information provided, or collected, in connection with this licensing
application in performing its functions and exercising its powers under the Financial
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 and designation of person taking the statutory declaration (as designated by the Oaths and Declarations Act
1957)
(Note: If you are making this declaration outside of New Zealand, please make sure it is sworn in accordance
with section 11 of the Oaths and Declarations Act 1957).
- Page 4 of 5 -
Date:
_______/_______/_______
Please initial here
•
•
•
DIR1.1Var
Checklist
Please confirm that you have attached/ included the following (please tick where applicable):
Your Curriculum Vitae / previously provided and no material change to content
(Delete as appropriate)
An explanatory statement, if required for one or more of questions 8 to 13.
- Page 5 of 5 -
Date:
_______/_______/_______
Please initial here
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Personal details DIRECTORSENIOR MANAGER STATUTORY DECLARATION FORM (Financial Markets Authority New Zealand)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document