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 oth FCA and PRA wesites at: https://www.handook.fa.org.uk/handook/sup/10a/anne x4.html http://www.ankofengland.o.uk/pra 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. Firms (not Inoming EEA) Appliation to perform ontrolled funtions under the approved persons regime FCA Handook Referene: SUP 10A Annex 4D PRA Handook Referene: SUP 10B Annex 4D 21 Marh 2016 Name of andidate (to e ompleted y appliant firm) Name of firm (as entered in 2.01) Firm referene numer (as entered in 2.02) Finanial Condut Authority 25 The North Colonnade Canary Wharf London E14 5HS United Kingdom Telephone +44 (0) 300 500 0597 Fasimile +44 (0) 207 066 0017 E-mail iva@fa.org.uk Wesite http://www.fa.org.uk Prudential Regulation Authority 20 Moorgate London EC2R 6DA United Kingdom Telephone +44 (0) 203 461 7000 E-mail PRA.firmenquiries@ankofengland.o.uk Wesite www.ankofengland.o.uk/pra The aove question(s) should e ompleted w hether sumission of this form is online or in one of the other ways set out in SUP
Personal identifiation details Setion 1 1.01 a Candidate Individual Referene Numer (IRN) OR name of previous regulatory ody AND previous referene numer (if appliale) 1.02 Title (e.g. Mr, Mrs, Ms, et) 1.03 Surname 1.04 ALL forenames 1.05 Name ommonly known y 1.06 Date of irth (dd/mm/yyyy) 1.07 National Insurane numer 1.08 Previous name 1.09 Date of name hange 1.10 a Nationality Passport numer (if National Insurane numer not availale) 1.11 Plae of irth I have supplied further information YES NO related to this page in Setion 6 1.12 a Private address The aove question(s) should e ompleted wh ether sumission of this form is online or in one of the o ther ways set ou t in SU P Appliation to perform ontrolled funtions under the approved persons regime Page 2
Postode Dates resident at this address (mm/yyyy) From To PRESENT (If address has hanged in the last three years, please provide addresses for the previous three years.) 1.13 a Previous address 1 Postode Dates resident at this address (mm/yyyy) From To 1.14 a Previous address 2 Postode Dates resident at this address From To (mm/yyyy) I have supplied further information YES NO related to this page in Setion 6 The aove question(s) should e ompleted wh ether sumission of this form is online or in one of the o ther ways set ou t in SU P Appliation to perform ontrolled funtions under the approved persons regime Page 3
Firm identifiation details Setion 2 2.01 Name of firm making the appliation 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 E-mail I have supplied further information related to this page in Setion 6 YES NO The aove question(s) should e ompleted wh ether sumission of this form is online or in one of the o ther ways set ou t in SU P Appliation to perform ontrolled funtions under the approved persons regime Page 4
Arrangements and ontrolled funtions Setion 3 3.01 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 f g Appointed representative/tied agent ustomer funtion AR firm name and referene numer Appointed representative/tied agent governing funtion AR firm name and referene numer Other Give details 3.02 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 3.05 a Signifiant influene funtions Signifiant influene funtions ontinued signifiant influene funtions ontinued Customer funtion CF 1 Diretor funtion CF 2 Non-exeutive diretor funtion CF 3 Chief exeutive funtion CF 4 Partner funtion CF 5 Diretor of an uninorporated assoiation funtion CF 6 Small friendly soiety funtion CF 8 Apportionment and oversight funtion (this funtion is not appliale to all firms please refer to Notes for Completing Form A) CF 10 Compliane oversight funtion CF 10a 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 CF 40 Benhmark sumission funtion CF 50 Benhmark administration funtion CF 30 Customer funtion The aove question(s) should e ompleted wh ether sumission of this form is online or in one of the o ther ways set ou t in SU P Appliation to perform ontrolled funtions under the approved persons regime Page 5
3.03 Effetive date of ontrolled funtions indiated aove 3.04 Jo title (mandatory for ontrolled funtion 28 & 29) Please refer to notes on the requirements for sumitting a CV In surane 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) YES YES NO NO I have supplied further information related to this page in Setion 6 YES NO The aove question(s) should e ompleted wh ether sumission of this form is online or in one of the o ther ways set ou t in SU P Appliation to perform ontrolled funtions under the approved persons regime Page 6
3.05 Complete this setion only if the appliation is on ehalf of more than one firm. List all firms within the group (inluding the firm entered in 2.01) for whih the andidate requires approval and the requested ontrolled funtion for that firm. Firm a Referene Numer Nam e of firm Controlled funtion Jo title (mandatory for ontrolled funtion 28 & 29) Effetive date d e I have supplied further information related to this page in Setion 6 YES NO The aove question(s) should e ompleted wh ether sumission of this form is online or in one of the o ther ways set ou t in SU P Appliation to perform ontrolled funtions under the approved persons regime Page 7
Employment history for past 5 years Setion 4 This setion has een removed. However if there has een a hange to the detail in this setion sine your last approval, you must sumit a Long form A as opposed to a Short Form A informing the FCA and/or PRA of the revised detail. The aove question(s) should e ompleted wh ether sumission of this form is online or in one of the o ther ways set ou t in SU P Appliation to perform ontrolled funtions under the approved persons regime Page 8
Fitness and propriety Setion 5 This setion has een removed. However if there has een a hange to the detail in this setion sine your last approval, you must sumit a Long Form A as opposed to a Short Form A informing the FCA and/or PRA of the revised detail. The aove question(s) should e ompleted wh ether sumission of this form is online or in one of the o ther ways set ou t in SU P Appliation to perform ontrolled funtions under the approved persons regime Page 9
Supplementary information Setion 6 6.00 If there is any other information the andidate or the firm onsiders to e relevant to the appliation, it must e inluded here. If this appliation relates to a Signifiant influene ontrolled funtion then please provide full details of o why the andidate is ompetent and apale to arry out the ontrolled funtion(s) applied for. o why the appointment omplements the firm's usiness strategy, ativity and market in whih it operates. o how the appointment was agreed inluding details of any disussions at governing ody level (where appliale). Please also inlude here any additional information indiated in previous setions of the Form. Please inlude a list of all diretorships urrently or previously held y the andidate in the past 10 years (where diretor has the meaning given in the Glossary.) If there is insuffiient spae, please ontinue on a separate sheet of paper and learly identify the setion and question to whih the additional information relates. Full details must e provided here if there were any issues that ould affet the Fitness and Propriety of the individual that arose when leaving an employer listed in setion 4 or if any question has een answered yes in setion 5. Question Information Please indiate how many additional sheets are eing sumitted The aove question(s) should e ompleted whether sumission of this form is online or in one of the other ways set out in SUP Appliation to perform ontrolled funtions under the approved persons regime Page 10
Delarations and signatures Setion 7 Delaration 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). 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. 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 au thorise the FCA and/or PRA to make suh enquiries and seek suh further information as it thinks a ppropriate in the ourse of verifying the informa tion gi ven in this Form. Ind ividual andidates may e required to ap ply 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 su mitting 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 (https://www.handook.fa.org.uk/handook/aper ) (http://www.ankofengland.o.uk/pra ) 7.01 Candidate's full name 7.02 Signature * Date * The aove question(s) appears on a paper form sumission only. That question does not appear on an eletroni form sumission. The aove question(s) should e ompleted whether sumission of this form is online or in one of the other ways set out in SUP Appliation to perform ontrolled funtions under the approved persons regime Page 11
Delaration 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 15.6.1R and SUP 15.6.4R 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 o n th e asis o f du e an d dilig ent en quiries mad e to d ate th at th e andidate is a fit an d proper person to perform the ontrolled funtion(s) listed in setion 3. Believes, on the asis of due and diligent enquiry, that the andidate is ompetent (inluding having ahieved the re levant qua lifiations) to fulfil the d uties re quired in the pe rformane of suh funtion(s). 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 3.05. 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 (https://www.handook.fa.org.uk/handook/aper) (http://www.ankofengland.o.uk/pra) 7.03 Name of the firm sumitting the appliation 7.04 Name of person signing on ehalf of the firm 7.05 Jo title 7.06 Signature * Date * The aove question(s) appears on a paper form sumission only. That question does not appear on an eletroni form sumission. The aove question(s) should e ompleted whether sumission of this form is online or in one of the other ways set out in SUP Appliation to perform ontrolled funtions under the approved persons regime Page 12