Individual Trustee Questionnaire "*" indicates required fields TO BE COMPLETED BY AN APPLICANT SEEKING APPROVAL AS AN INDIVIDUAL TRUSTEE UNDER THE PENSION TRUST FUNDS ACT 1966 Personal QuestionnairePlease read the questions carefully. If more space is needed the answers should be written in the space provided at the end of this questionnaire headed “Additional Information.” Clearly state to which question the details relate. When you return this form please ensure you enclose a full CV. The areas covered in this questionnaire are not exhaustive of the matters that the Pension Commission will consider in assessing whether a person is “Fit and Proper”. I.Name of Pension Trust Fund in connection with which this questionnaire is being completed* Surname* Forename(s)* Contact No.* Email* Maiden Name (if applicable)* Any previous name(s)* Date of birth* DD dash MM dash YYYY Place of birth Country of citizenship* Residential address (not P O Box)* Nationality* Previous nationality* II. Specific responsibilities within trustees (if any).III. Are you affiliated or a representative of the Employer Union, Administrator or other service provider?* Yes No If yes state which one. IV. Details of any educational and professional qualifications and the year in which they were obtained.Professional QualificationYear ObtainedV. Details of current membership of any relevant professional bodies, their address(es) and the year of admission.Professional BodyAddressYear of AdmissionVI. Present occupation or employment and occupations and employment during the last 10 years including the full name and address of the employer, the nature of the business, the position held and the relevant dates (a full CV should be attached).Name/Address EmployerNature of BusinessPosition HeldRelevant DatesVII. Please answer Yes or No to the following questions. If any of the answers to the questions below are yes, please give full particulars in the space provided at the back of this questionnaire clearly stating to which question the details relate.a. Have you at any time been a director, officer or senior executive of any institution whose licence to conduct any financial services business has during the period of your involvement or within 12 months thereafter, been revoked, cancelled, restricted, suspended or surrendered under any law?* Yes No b. Have you at any time been a director, officer or senior executive of any institution whose application for a licence to conduct banking, investment, trust, insurance or other financial services business in Bermuda or elsewhere has during the period of your involvement or within 12 months thereafter, been refused or withdrawn?* Yes No c. Have you at any time been convicted of any offence by any court, in Bermuda or elsewhere? If so, when giving particulars detail the court by which you were convicted, the offence, the penalty imposed and the date of conviction. (Exclude 1. Any offence committed when you were under 18 years unless it was committed within the last 10 years; 2. Any road traffic offence; 3 Any offence that, for the purpose of the Rehabilitation of Offenders Act 1977 should be treated as spent).* Yes No d. Have you, in Bermuda or elsewhere, been censured, disciplined or criticized by any professional body to which you belong or have belonged or made the subject of a court order at the instigation of any regulatory authority or have you ever held a practicing certificate subject to conditions?* Yes No e. Have you, or has any company, partnership or unincorporated institution with which you are, or have been associated as a director, officer or senior executive, by reason of any matters relating to it at a time when you were so associated, been the subject of an investigation, in Bermuda or elsewhere, by a governmental, professional or other regulatory body?* Yes No f. Have you incurred a judgement debt under an order of a court in Bermuda or elsewhere or made any compromise arrangement with your creditors within the last 10 years?* Yes No g. Have you in Bermuda or elsewhere, been dismissed from any office or employment or barred from entry to any profession or occupation?* Yes No h. Has any company, partnership or unincorporated institution with which you were associated as a director, officer or senior executive in Bermuda or elsewhere been wound up or otherwise made any compromise or arrangement with its creditors or ceased trading, either when you were associated with it or within one year after you ceased to be associated with it? Has anything analogous to any of these events occurred under the laws of any other jurisdiction?* Yes No i. Have you been concerned with the management or conduct of affairs of any institution which, by reason of any matter relating to it at a time when you were so concerned, has been censured, warned as to future conduct, disciplined or publicly criticised by or made the subject to a court order at the instigation of any regulatory authority in Bermuda or elsewhere?* Yes No j. Have you, in connection with the formation or management of any body corporate, partnership or unincorporated institution, been adjudged by a court in Bermuda or elsewhere to have civil liability for any fraud, misfeasance or other misconduct by you towards such a body or company or towards any members thereof?* Yes No k. Are you presently or do you expect to be engaged in any litigation in Bermuda or elsewhere?* Yes No CERTIFICATIONI,* certify that the above information is complete and correct to the best of my knowledge and belief.Signed* Reset signature Signature locked. Reset to sign again Date* DD dash MM dash YYYY Upload CV*Max. file size: 10 MB.ADDITIONAL INFORMATION(Please state clearly to which questions the details relate)
