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SUPPORTING INFORMATION CHECKLIST AND STATUTORY DECLARATION FINANCIAL MARKETS (Financial Markets Authority New Zealand)

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TRU2.1
SUPPORTING INFORMATION CHECKLIST AND STATUTORY DECLARATION
INFORMA
TION FOR LICENSING UNDER SECTION 16 OF THE
FINANCIAL MARKETS SUPERVISORS ACT 2011 (The Act)
Applicant company details:
1. Company name (as registered):
2.
Company Financial Service Provider
(FSP) number:
Director/senior manager details:
Please complete and submit with this form a DIR1.1 form for each and every director and senior
manager as required by Section 16 of the Act.
3. Please identify the name and position of each director/senior manager submitting a DIR1.1
form for the applicant entity by completing Appendix 1.
I confirm that all the required directors and senior managers have completed DIR1.1
forms, and their names are listed in Appendix 1.
- Page 1 of 5 -
Date:
_______/_______/_______
Please initial here
TRU2.1
Application document checklist:
4.
As a part of an application for licensing, the applicant entity is required to provide a number of
documents in support of their application. Please confirm that you have supplied the required
documents with this form by ticking the appropriate boxes.
Provid
ed with
Tru2.1 form
i. Business details
ii. Good character (DIR1.1 Forms)
iii. FSP (RDR) Act compliance
iv. Experience, skills and qualifications
v. Compliance controls
vi. Compliance monitoring
vii. Financial resources
viii. Other resources
ix. Independence
x. Governance
xi. Professional indemnity insurance
xii. Other matters
Please ensure that you use the cover pages provided in Appendix 2 to identify the
documents being submitted for assessment.
- Page 2 of 5 -
Date:
_______/_______/_______
Please initial here
Please refer to Part C of the ‘Guidance Note: Supervisor Licensing’ to help you answer what’s required by
the FMA for each of the headings in the document.
TRU2.1
Confirmation
I confirm that prior to completing this application, I understand the entity’s obligations under the Act, and the
Financial Markets Supervisors Regulations 2014, and I have read and understood the Guidance Note: Supervisor
Licensing issued by the Financial Markets Authority.
I confirm (please tick those statements that are applicable):
Debt securities and/or Registered Schemes
The applicant is currently registered under the Financial Service Providers (Registration
and Dispute Resolution) Act 2008.
Retirement Villages:
The applicant, being an applicant for a licence that covers a retirement village, is compliant
with section 13 (a) of the Financial Service Providers (Registration and Dispute
Resolution) Act 2008.
Statutory declaration
I, _______________ _______________ _______________, of __________________________________________
solemnly and sincerely declare the following:
that I have been authorised to act on behalf of the applicant in this application
that having conducted all necessary enquiries, I declare the information provided in this form to be true
and correct to the best of my knowledge.
Signature of person making declaration
Declared at this day of 20
before me:
Full nam
e and designation of person to take statutory declaration
(Note: If you are making this declaration outside New Zealand, please ensure it is sworn in
accordance with section 11 of the Oaths and Declarations Act 1957).
- Page 3 of 5 -
Date:
_______/_______/_______
Please initial here
•
•
TRU2.1
Name
Role within applicant’s business
First name
Last name
- Page 4 of 5 -
Date:
_______/_______/_______
Please initial here
Appendix 1
TRU2.1
Name
Role within applicant’s business
First name
Last name
- Page 5 of 5 -
Date:
_______/_______/_______
Please initial here
Appendix 2
TRU2.1
1. Business details
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided i
n this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
2. Good character (DIR1 Forms)
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided i
n this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
3. FSP (RDR) Act compliance
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided i
n this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
4. Experience, skills and qualifications
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided i
n this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
5. Compliance controls
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided i
n this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
6. Compliance monitoring
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided in
this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
7. Financial resources
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided i
n this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
8. Other resources
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided in
this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
9. Independence
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided in
this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
10. Governance
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided i
n this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
11. Professional indemnity insurance
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided in
this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
12. Other matters
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided i
n this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1
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SUPPORTING INFORMATION CHECKLIST AND STATUTORY DECLARATION FINANCIAL MARKETS (Financial Markets Authority New Zealand)

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Completed 15 November 2020

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