Full Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Address (If you have lived at your current address less than three years)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you need a Work Permit to be employed in the UK?

Yes

No

Are you or have you ever been registered with the FCA, PRA or FSA?

You can search for your number via - https://register.fca.org.uk/s/

Yes

No

Are you assessed as competent under your current Training & Competence scheme?

Yes

No

N/A

Address of Employer

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of First Referee

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please confirm if we can obtain this reference now *

Yes

No

Name of Second Referee

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please confirm if we can obtain this reference now

Yes

No

Name of Third Referee

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please confirm if we can obtain this reference now

Yes

No

Name of Fourth Referee

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please confirm if we can obtain this reference now

Yes

No

1 a Have you ever been convicted of any offences involving fraud, theft, false accounting, serious tax offences or other dishonesty or an offence (whether or not in the United Kingdom) relating to companies, building societies industrial and provident societies, credit unions, friendly societies, insurance banking or other financial services, insolvency consumer credit or consumer protections, money laundering, market manipulations or insider dealing? (Please note: spent convictions need not be disclosed, however, if your role requires FCA approval you will need to provide this information as part of the approval process)

Yes

No

b Are you the subject of any current criminal proceedings? *

Yes

No

c Have you ever been given a caution in relation to any criminal offence? *

Yes

No

d Have you any convictions for any offences other than those listed in question 1 a) above which are not spent, whether or not in the United Kingdom (excluding traffic offences unless these resulted in a ban from driving or involved driving without insurance)? *

Yes

No

2 a Are you or have you ever been the subject of any civil proceedings, arbitration or litigation, including proceedings that resulted in a County Court Judgment (CCJ) or other judgement debts, in the United Kingdom or elsewhere?

Yes

No

b Are you aware of any intention to begin such proceedings against you in the future? *

Yes

No

c Do you have any judgement debts (including CCJs) made under a court order still outstanding, whether in full or in part? *

Yes

No

d Have you ever failed to satisfy any such judgement debts within one year of making of the order? *

Yes

No

3 a Are you or have you ever been, the subject of any bankruptcy proceedings, or proceedings for the sequestration of your estate?

Yes

No

b Have you ever entered into a deed of arrangement or an individual voluntary arrangement (or in Scotland a trust deed) or other agreement in favour of your creditors, or are you doing so?

Yes

No

4 Have you ever been found guilty of conducting any unauthorised regulated activities or been investigated for possible conduct of unauthorised regulated activities?

Yes

No

5 Are you, or have you ever been, the subject of an investigation into allegations of misconduct or malpractice in connection with any business activity?

Yes

No

6 Have you ever, either in the United Kingdom, or elsewhere –

a been refused entry to, or been dismissed or requested to resign from, any profession, vocation, office or employment, or from any fiduciary office or position of trust, whether or not remunerated?

b been refused, restricted in, or had suspended, the right to carry on any trade, business or profession for which specific licence, authorisation, registration, membership or other permission is required?

c been disqualified by a court from acting as a director of a company or from acting in a management capacity of conducting the affairs of any company, partnership or unincorporated association?

d been the subject of a disqualification direction under section 59 of the Financial Services Act 1986 of a prohibition order, under section 56 of the Financial Services and Markets Act 2000, or received a warning notice to make such a direction or order?

e None of the above

7 Do you have any outside employment or positions other than other than one which is a part of the company – If yes, please provide full details in Supplementary Notes below.

Yes

No

8 Have you ever been a controller, director, senior manager, and partner or company secretary of a company, partnership, or unincorporated association?

Yes

No

9 In respect of activities regulated by the FCA have you, or any company, partnership or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, during your association with that entity and for a period of three years after you ceased to be associated with it, ever –

a been refused, had revoked, restricted or terminated any licence, authorisation, registration, notification, membership or other permission granted by any such body?

b been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action by any such body?

c resigned whilst under investigation by, or been required to resign from, any such body?

d been the subject of any civil action which has resulted in a finding against you or it by a court?

e Received a warning (whether public or private) that such disciplinary or interventional action may be taken against you or the firm?

f Been the subject of an investigation by any regulatory body, whether or not such an investigation resulted in a finding against you or the firm?

g Been required or requested to produce documents or any other information to any regulatory body in connection with such an investigation (whether against the firm or otherwise)?

h Ceased operating or resigned whilst under investigation by any such body or been required to cease operating or resign by any regulatory body?

i Decided, after making an application for any licence, authorisation, registration, notification, membership or any permission granted by any such body, not to proceed with it?

j Been found to have carried on activities for which authorisation or registration by the FCA/PRA or any other regulatory body is required without the requisite authorisations?

k Been found to have performed a controlled function (or an equivalent function requiring approval by the FCA/PRA or any other regulatory body) without the requisite approval?

l Been investigated for the possible performance of a controlled function (or an equivalent function requiring approval by the FCA/PRA or any other regulatory body) without the requisite approval, whether or not such Yes No investigation resulted in a finding against you?

m None of the above

10 Has any company, partnership or unincorporated association for which you have been a controller, director, senior manager, partner or company secretary, in the United Kingdom or elsewhere, at any time during your involvement or within three years of such an involvement –

a been put into liquidation, wound up, ceased trading, had a receiver or administrator appointed or entered into any voluntary arrangement with its creditors?

b been declared by a court liable for any fraud, misfeasance, wrongful trading or other misconduct?

c been investigated or been involved in an investigation by an inspector appointed under companies or any other legislation, or required to produce documents to the Secretary of State, or any other authority, under any such legislation?

d been convicted of any criminal offence, censured, disciplined or publicly criticised, by any inquiry, by the Takeover Panel of any other governmental or statutory authority or any other regulatory body

e Adjudged by a court civilly liable for any fraud, misfeasance, wrongful trading or other misconduct?

f The subject of a judgement debt or award against the firm? (You should include all CCJs made against the firm, whether satisfied or not.)

g None of the above

11a. Have any of the firms that you have been associated with been removed from a lenders panel?

Yes

No

N/A

12. Have you ever been dismissed / asked to leave by an employer or if self employed, had your contract terminated?

Yes

No

13. Have you ever resigned whilst under investigation or suspension?

Yes

No

14. Have you ever received any warnings either verbal or written?

Yes

No

15. Has there ever been an investigation or review carried out on you or business conducted by you?

Yes

No

16. Have you ever been suspended or had your licences suspended? (e.g employer, network, lender or provider?)

Yes

No

17. Have you ever had an application declined by an employer, network, provider or lender which you have applied to?

Yes

No

18. Have you ever had any complaints upheld against you?

Yes

No

Document Checklist

Passport / Driving Licence

Proof of Address - Dated in last 3 months

Copy of CeMAP (or equivalent) Certificate (if applicable to role)

Copy of an updated CV

Copy of an updated Credit Report ( a free copy can be obtained via www.checkmyfile.com)

Your Name *

First Name

Last Name