TRU1.1
APPLICATION FORM FOR FINANCIAL MARKETS SUPERVISORS LICENCE
(FOR A NEW LICENCE OR TO REPLACE AN EXPIRING LICENCE)
Applicant company details:
1. Company n
ame (as registered):
2. Company n
umber:
3. Company Fin
ancial Service Provider (FSP)
Number (if app
licable):
4. Registere
d company address:
Street number
(
or PO Box)
Street name
Suburb
Town or city
Postcode
Licence details
5. Please select
ONE or more of the following as appropriate:
The applicant seeks a licence as a supervisor for debt securities
The applicant seeks a licence as a supervisor for registered schemes. Please
indicate which category(s) below:
a)
KiwiSaver schemes
b)
Non-fund schemes
c)
Specified managed funds
d)
Superannuation schemes.
The applicant seeks a licence as a statutory supervisor for retirement villages
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Date:
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TRU1.1
6. If you have ticke
d either of the first 2 boxes under Q5, please select ONE of the following:
The applicant seeks to be licensed for debt securities and/or registered schemes,
generally The applicant seeks to be licensed for specific debt securities and/or specific
registered schemes (please list these in Appendix 1)
7. If you have ticked t
he last box of Q5, please select ONE of the following:
The applicant seeks to be licensed for retirement villages generally
The applicant seeks to be licensed for specific retirement villages (please list
in Appendix 2)
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Date:
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Contact details:
8.
Contact name:
9.
Contact email address:
10.
Contact phone number:
Declaration
11. I confirm this applicant and the applicant’s governing body have authorised me to apply for this
licence.
12. After having conducted all the necessary enquiries, I declare the information provided in this form is
true and correct to the best of my knowledge.
Name of individual completing form on behalf of the applicant entity:
Signed: Dated: / /
TRU1.1
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Date:
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Fee details, how to pay your fee and how to submit your application
Application fee: $8,021.25
Full amount payable $8,021.25
Payment of $8,021.25 by internet banking or
At a Westpac branch
Hourly rate payable if 52 hours exceeded:
Qualified FMA Employee: $178.25
FMA Board Member: $230.00
Fees
Financial Markets Authority (Fees) Regulations 2011
Please note that payment by Credit Card is not available for this application process.
How to submit your application
Completed PDF versions of the application form, declarations and supporting forms can be submitted to the
FMA by email to renewals@fma.govt.nz. Alternatively, the completed application form and supporting
documents can be submitted in one package to the FMA addressed to;
Licensing Manager
Level 2
1 Grey Street
PO Box 1179
Wellington 6140
Internet banking
Payment option How do I pay? Additional information
Select the bill payment option.
Our bank details are:
Bank name: Westpac
Account name: Financial Markets
Authority
Account number: 03 0584
0198005 002
To ensure we process your payment
correctly you need to provide the
following information:
Particulars: Full name of business
applying for the licence
Code: Supervisors
Reference: FSP number (if
registered)
Westpac branch
Call in to your nearest Westpac
branch and pay your fee by cash,
cheque, Eftpos or Smart ATM.
To ensure we process your payment
correctly you need to provide the
following information:
Particulars: Full name of business
applying for the licence
Code: Supervisors
Reference: FSP number (if
registered)
How to pay
TRU1.1
Appendix 1:
Debt securities and/or registered scheme for which licence is sought
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
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Date:
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TRU1.1
Appendix 2:
Retirement villages for which licence is sought
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
- Page 5 of 5 -
Date:
_______/_______/_______
Please initial here
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