Form E Internal transfer of an approved person
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1 Appliation numer (for FCA/PRA use only) The FCA and PRA have produed notes whih will assist oth the appliant and the andidate in answering the questions in this form. Please read these notes, whih are availale on the FCA and PRA s wesites at and Both the appliant and the andidate will e treated y the FCA and PRA as having taken these notes into onsideration when ompleting their answers to the questions in this form. Form E Internal transfer of an approved person FCA Handook Referene: SUP 10A Annex 8D PRA Handook Referene: SUP 10B Annex 8D 21 Marh 2016 Name of andidate (to e ompleted y appliant firm) Name of firm (as entered in 2.01) Finanial Condut Authority 25 The North Colonnade Canary Wharf London E14 5HS United Kingdom Telephone +44 (0) Fasimile +44 (0) iva@fa.org.uk Wesite Prudential Regulation Authority 20 Moorgate London EC2R 6DA United Kingdom Telephone +44 (0) PRA.firmenquiries@ankofengland.o.uk Wesite Form E Internal transfer of an approved person Page 1
2 Personal identifiations details Setion Individual Referene Numer (IRN) 1.02 Title (e.g. Mr, Mrs, Ms, et) 1.03 Surname 1.04 ALL forenames 1.05 Date of irth 1.06 National Insurane numer Firm identifiation details Setion Name of firm 2.02 Firm Referene Numer (FRN) 2.03 a Who should the FCA/PRA ontat at the firm in relation to this appliation? Position Telephone d Fax e related to this page in Setion 5 Form E Internal transfer of an approved person Page 2
3 Controlled funtions to ease Setion List all ontrolled funtions whih the approved person is easing to perform. The effetive date is the date the person will ease to perform the funtions. a FRN Name of firm Controlled funtion Effetive date d e related to this page in Setion 5 Form E Internal transfer of an approved person Page 3
4 New arrangements and ontrolled funtions Setion Nature of the arrangement etween the andidate and the appliant. a Employee Group employee Name of group Contrat for servies d Partner/Sole trader e Appointed representative ustomer funtion Name of AR f Appointed representative governing funtion Name of AR g Other Give details 4.02 For appliations from a single firm, please tik the oxes that orrespond to the ontrolled funtions to e performed. If the ontrolled funtions are to e performed for more than one firm, please go to question 4.05 a Signifiant influene funtions CF 1 CF 2 CF 3 CF 4 CF 5 CF 6 Diretor funtion Non- exeutive diretor funtion Chief exeutive funtion Partner funtion Diretor of an uninorporated assoiation funtion Small friendly soiety funtion related to this page in Setion 5 Form E Internal transfer of an approved person Page 4
5 Signifiant influene funtions ontinued CF 8 Apportionment and oversight funtion (Non-MiFID usiness Only) CF 9 EEA investment usiness oversight funtion (Non-MiFID usiness Only) CF 10 Compliane oversight funtion (Non-MiFID usiness Only) CF 10 A CASS operational oversight funtion CF 11 Money laundering reporting funtion CF 12 Atuarial funtion CF 12A With-profits atuary funtion CF 12B Lloyd's Atuary funtion CF 28 System and ontrols funtion CF 29 Signifiant management funtion signifiant influene funtions ontinued CF 40 Benhmark sumission funtion CF 50 Benhmark administration funtion Customer funtion CF 30 Customer funtion 4.03 Effetive date of ontrolled funtions indiated aove 4.04 Jo title (mandatory for ontrolled funtion 28 & 29) Insurane mediation Will the andidate e responsile for Insurane mediation at the firm? (Note: Yes an only e seleted if the individual is applying for (CF1,3-8 or 29) Mortgage Credit Diretive Intermediation Will the andidate e responsile for Mortgage Credit Diretive Intermediation at the firm? (Note: Yes an only e seleted if the individual is applying for (CF1, 3-8 or 29) related to this page in Setion 5 Form E Internal transfer of an approved person Page 5
6 4.05 List all firms within the group (inluding the firm entered in 4.02) for whih the appliant requires approval and the requested ontrolled funtion for that firm. a Firm Referene Numer Name of firm Controlled funtion Jo title (mandatory for ontrolled funtion 28 & 29) Effetive date d e related to this page in Setion 5 Form E Internal transfer of an approved person Page 6
7 Supplementary Information Setion Is there any other information the andidate or the firm onsiders to e relevant to the appliation? If yes, please provide details elow or on a separate sheet of paper and learly identify the setion and question to whih the additional information relates. Question Information 5.02 How many additional sheets are eing sumitted? Form E Internal transfer of an approved person Page 7
8 Delarations and signatures Setion 6 DECLARATION OF CANDIDATE Knowingly or reklessly giving the FCA and/or PRA information whih is false or misleading in a material partiular may e a riminal offene (setion 398 of the Finanial Servies and Markets At 2000). APER 4.4.7E provides that, where an approved person is responsile for reporting matters to the FCA and/or PRA, failure to inform the FCA and/or PRA of materially signifiant information of whih he is aware is a reah of Statement of Priniple 4. Contravention of these requirements may lead to disiplinary santions or other enforement ation y the FCA and/or PRA It should not e assumed that information is known to the FCA and/or PRA merely eause it is in the puli domain or has previously een dislosed to the FCA and/or PRA or another regulatory ody. If there is any dout aout the relevane of information, it should e inluded. I onfirm that the information in this Form is aurate and omplete to the est of my knowledge and elief and that I have read the notes to this Form. For the purposes of omplying with the Data Protetion At, the personal information provided in this Form will e used y the FCA and/or PRA to disharge its statutory funtions under the Finanial Servies and Markets At 2000 and other relevant legislation, and will not e dislosed for any other purpose without the permission of the appliant. With referene to the aove, the FCA and/or PRA may seek to verify the information given in this Form inluding answers pertaining to fitness and propriety. This may inlude a redit referene hek. In signing the form elow: a) I authorise the FCA and/or PRA to make suh enquiries and seek suh further information as it thinks appropriate in the ourse of verifying the information given in this Form. Individual andidates may e required to apply to the Criminal Reords Bureau for a searh to e made as to whether any riminal reords are held in relation to them and to dislose the result of that searh to us. I also understand that the results of these heks may e dislosed to the firm sumitting this appliation. ) I onfirm that the information in this Form is aurate and omplete to the est of my knowledge and elief and that I have read the notes to this Form. ) I onfirm that I understand the regulatory responsiilities of my proposed role as set out in the Statements of Priniple and Code of Pratie for Approved Persons ( ( Candidate's full name 6.02 Signature * Date * The aove question(s) appears on a paper form sumission only. That question does not appear on an eletroni form sumission. Form E Internal transfer of an approved person Page 8
9 Delarations and signatures Setion 6 DECLARATION OF FIRM Knowingly or reklessly giving the FCA and/or PRA information whih is false or misleading in a material partiular may e a riminal offene (setions 398 and 400 of the Finanial Servies and Markets At 2000). SUP R and SUP R require an authorised person to take reasonale steps to ensure the auray and ompleteness of information given to the FCA and/or PRA and to notify the FCA and/or PRA immediately if materially inaurate information has een provided. APER 4.4.7E provides that, where an approved person is responsile for reporting matters to the FCA and/or PRA, failure to inform the FCA and/or PRA of materially signifiant information of whih he is aware is a reah of Statement of Priniple 4. Contravention of these requirements may lead to disiplinary santions or other enforement ation y the FCA and/or PRA It should not e assumed that information is known to the FCA and/or PRA merely eause it is in the puli domain or has previously een dislosed to the FCA and/or PRA or another regulatory ody. If there is any dout aout the relevane of information, it should e inluded. In making this appliation the firm Believes on the asis of due and diligent enquiries made to date that the andidate is a fit and proper person to perform the ontrolled funtion(s) listed in setion 4. Believes on the asis of due and diligent enquiry, that the andidate is ompetent (inluding having ahieved the relevant qualifiations) to fulfil the duties required in the performane of suh funtion(s). IF UNDERTAKING ANY N MiFID BUSINESS FOR WHICH YOU HAVE T PREVIOUSLY APPLIED FOR AUTHORISATION, PLEASE ALSO COMPLETE THE FOLLOWING The firm also elieves, on the asis of due and diligent enquiry, that the andidate is ompetent to fulfil the duties required of suh funtion(s). I onfirm that the information in this Form is aurate and omplete to the est of my knowledge and elief and that I have read the notes to this Form. I onfirm that I have authority to make this appliation, and sign this Form, on ehalf of eah firm identified in setion I also onfirm that a opy of this Form, as sumitted to the FCA and/or PRA, will e sent to eah of those firms at the same time as sumitting the Form to the FCA and/or PRA. In signing this form on ehalf of the firm: a) I onfirm that the information in this Form is aurate and omplete to the est of my knowledge and elief and that I have read the notes to this Form. ) I onfirm that I have authority to make this appliation, and sign this Form, on ehalf of eah firm identified in setion I also onfirm that a opy of this Form, as sumitted to the FCA and/or PRA will e sent to eah of those firms at the same time as sumitting the Form to the FCA and/or PRA ) I onfirm the andidate has een made aware of the regulatory responsiilities of the proposed role as set out in the Statements of Priniple and Code of Pratie for Approved Persons ( ( Name of the firm sumitting the appliation 6.04 Name of person signing on ehalf of the firm 6.05 Jo title 6.06 Signature * Date * The aove question(s) appears on a paper form sumission only. That question does not appear on an eletroni form sumission. Form E Internal transfer of an approved person Page 9
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