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
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
the FMA to disclose personal information to the third party
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
Full name and designation of person taking the statutory declaration (as designated by the Oaths and Declarations Act
(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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