Personal Questionnaire – Pension Commission Bermuda

"*" indicates required fields

Please read the questions carefully. If more space is needed the answers should be written in the space provided at the back of this questionnaire headed “Additional Information.” Clearly state to which question the details relate. Answers should be written in ink in BLOCK CAPITALS or typed. 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.”

Name of applicant in connection with which this questionnaire is being completed*

Position with applicant*

Surname*

Forename(s)*

Maiden Name (if applicable)

Any previous name(s)

Date of birth*

MM slash DD slash YYYY

Place of birth

Residential address*

Country of citizenship*

Nationality*

Previous nationality

Email*

II. A) Specific responsibilities within applicant (if any).

III. Details of any educational and professional qualifications and the year in which they were obtained.

Professional Qualification

Year Obtained

IV. Details of current membership of any relevant professional bodies, their address(es) and the year of admission.

Professional Body

Address

Year of Admission

V. 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 Employer

Nature of Business

Position Held

Relevant Dates

VI. Name any companies of which you are (or have been in the last 10 years) a director, significant shareholder (10% ownership or above), manager or officer and the countries in which they are registered. If your relationship with the company has ceased, please give the date on which it terminated.

Name of Company

Country of Registration

Capacity or Nature of Relationship

VII. 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to conduct any financial services business has during the period of your involvement or within 12 months thereafter, been revoked, cancelled, restricted, suspended or surrendered under any law?*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

b. Have you at any time been a director, officer or senior executive of any institution whose application for a licence to conduct investment business 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

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

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

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

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

g. Have you in Bermuda or elsewhere, been dismissed from any office or employment or barred from entry to any profession or occupation?*

Yes

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

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

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

k. Are you presently or do you expect to be engaged in any litigation in Bermuda or elsewhere, other than in a professional capacity?*

Yes

CERTIFICATION

I certify that the above information is complete and correct to the best of my knowledge and belief.

Name*

Signature

Date

DD dash MM dash YYYY

ADDITIONAL INFORMATION

(Please state clearly to which questions the details relate)

CERTIFICATION

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