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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:
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Date:
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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.
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Date:
_______/_______/_______
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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
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Date:
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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).
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Date:
_______/_______/_______
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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.
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Date:
_______/_______/_______
Please initial here
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