ASSOCIATE MEMBERSHIP APPLICATION FORM OCTOBER 2016
Company Name FMDQ OTC SECURITIES EXCHANGE ASSOCIATE MEMBERSHIP APPLICATION FORM APPLICANT INFORMATION RC Number Registered Office Address Date of Incorporation Place of Incorporation Company Telephone Number(s) Company Email Address Corporate Website Address Nature of Business Authorised Share Capital Paid-up Share Capital Application Primary Contact Details Telephone/Mobile Number: Email
MEMBERSHIP SUB-CATEGORY (See Appendix 1 for description of each sub-category) 1. Associate Member (Inter-Dealer Broker) [AMI]: 2. Associate Member (Broker) [AMB]: 3. Associate Member (Client) [AMC]: Product of Interest: TRADING DETAILS a. Bonds B. c. Treasury Bills D. e. Commercial Papers F. g. Foreign Exchange * (Kindly refer to Additional Requirements for Associate Member (Clients) FX) i. Derivatives J. k. Others 1 L. Direction of Trades: a. Buy b. Sell H. c. Both Transaction Details : a. Bonds b. Treasury Bills c. Commercial Papers d. Foreign Exchange e. Derivatives Monthly Average Value Of Trades Per Product ( ) BANK DETAILS Average Trade Size Per Transaction ( ) 1. Telephone: Mobile No. of Account Manager: 1 In a separate sheet, kindly specify any other product of interest detailing the monthly average value of trades per product and average trade size per transaction ( )
Email Address of Account Manager: Type of Account: 2. Telephone: Email Address of Account Manager: Type of Account: Mobile No of Account Manager: CUSTODIAN INFORMATION Telephone: Mobile No. of Contact: KEY OFFICERS MANAGING DIRECTOR/CHIEF EXECUTIVE OFFICER TREASURER/CHIEF FINANCIAL OFFICER CHIEF COMPLIANCE OFFICER (where applicable) INTERNAL AUDITOR (where applicable) RISK MANAGEMENT OFFICER (where applicable)
DISCIPLINARY HISTORY The questions below relate to the company and the key officers listed above. Responses should cover material events which occurred in the past ten (10) years and should include events that have occurred anywhere in the world. If in doubt as to the materiality or relevance of the event, please disclose the event. If the answer to the any of the questions below is YES, the applicant is required to provide additional information/details in a separate sheet. THE COMPANY Has the company or any of its affiliates 2, been denied registration or expelled from membership of any securities exchange, self-regulatory organisation (SRO) or associations? Has your membership, or that of any affiliates, in any of the institutions/associations mentioned above at any time been revoked, suspended or withdrawn? YES or NO Has your company, or any of its affiliates, ever been refused any Fidelity Bond? Has your company, or any of its affiliates, been subject to any winding up order/receivership arrangement? preceding this application for the filing of any application for registration? preceding this application for the purchase or sale of securities? preceding this application for any offence relating to the code of the business of Broker/Dealer, Issuing House, Investment Adviser, Bank or Insurance or such other related function? preceding this application for any criminal offence? preceding this application for any civil offence? MANAGING DIRECTOR/CHIEF EXECUTIVE OFFICER YES or NO Ever been convicted of any criminal offence? Ever been the subject of an adverse finding by, or settlement with, any government agency, court, securities exchange, SRO, tribunal or other regulatory authority? Ever been a director, partner or otherwise concerned in the management of a business which has gone into insolvency, liquidation, administration or the similar proceedings within or outside of the Nigerian jurisdiction while connected with such organisation within one (1) year of that connection? Ever been declared bankrupt or entered into any compromise arrangement with creditors related to bankruptcy or insolvency? 2 An affiliate, for the purpose of this application form, is a company or partnership in which the company (applicant) has at least 20% ownership interest however so called
Ever been the subject of any disciplinary or criminal proceedings or been the subject of any investigation by any authority which may lead to such proceedings? Ever been refused authorisation or licence to carry on a trade, business or profession or to be a member of a securities exchange? Ever had such authorisation, membership or licence (referred to above) revoked or terminated? Ever been disqualified from acting as a Director? TREASURER/CHIEF FINANCIAL OFFICER YES or NO Ever been convicted of any criminal offence? Ever been the subject of an adverse finding by, or settlement with, any government agency, court, securities exchange, SRO, tribunal or other regulatory authority? Ever been concerned in the management of a business which has gone into insolvency, liquidation, administration or the similar proceedings within or outside of the Nigerian jurisdiction while connected with such organisation within one (1) year of that connection? Ever been declared bankrupt or entered into any compromise arrangement with creditors related to bankruptcy or insolvency? Ever been the subject of any disciplinary or criminal proceedings or been the subject of any investigation by any authority which may lead to such proceedings? CHIEF COMPLIANCE OFFICER Ever been convicted of any criminal offence? YES or NO Ever been the subject of an adverse finding by, or settlement with, any government agency, court, securities exchange, SRO, tribunal or other regulatory authority? Ever been concerned in the management of a business which has gone into insolvency, liquidation, administration or the equivalent proceedings within or outside of the Nigerian jurisdiction while connected with such organisation within one (1) year of that connection? Ever been declared bankrupt or entered into any compromise arrangement with creditors related to bankruptcy or insolvency? Ever been the subject of any disciplinary or criminal proceedings or been the subject of any investigation by any authority which may lead to such proceedings?
SUPPORTING DOCUMENTS 3 (TICK IF ENCLOSED) Company Profile containing brief description of the following, inter alia: History & Company Overview Details of Business Services Profiles of Board of Directors Profiles of Executive Management Staff Certificate of Incorporation Memorandum and Articles of Association Particulars of Directors CAC Form 7 Particulars of Shareholders CAC Form 2 [for Private Companies (Ltd.) only] Evidence of registration with the Securities and Exchange Commission (SEC), Nigeria [where applicable] Most recent One (1) year Audited Financial Statements, not exceeding 18 months from end of the last financial year List of Authorised Representatives 4 (stating their designations) Detailed resumes of SEC-registered Sponsored Individuals [where applicable] Latest Fidelity Bond [where applicable] Evidence of compliance with the minimum paid-up capital as stipulated by SEC/Central Bank of Nigeria (CBN) (if applicable) Brief Description of Technology Infrastructure detailing the following: Internet Service Provider Internet Service Bandwidth Available System Specifications Specifications of the computers that will be dedicated for trading Data Centre Security Features Evidence of Payment of Application Fee and Membership Dues (Click here for FMDQ Fees and Dues Framework) Nigerian Stock Exchange (NSE) Stockbroking Licence (for NSE-licenced stockbrokers only) 3 Note: FMDQ reserves the right to request additional information and documentation from time to time, where necessary. Upon successful filing of the above documents, the applicant will be required to execute a membership agreement with FMDQ before the registration can be deemed complete 4 Authorised Representatives are persons authorised by the Member to make representations to FMDQ on its behalf in respect of its membership on the FMDQ platform
ADDITIONAL REQUIREMENTS FOR ASSOCIATE MEMBER (BROKERS) Evidence of minimum shareholders funds of N500,000,000.00 (Five Hundred Million Naira) only Confirmation of technical knowledge of sponsored individuals in fixed income dealing operations ADDITIONAL REQUIREMENTS FOR ASSOCIATE MEMBER (CLIENTS) FX Letter of expression of interest to be an Associate Member (Client) FX of FMDQ** Letter of introduction from an FMDQ-licenced Dealing Member (Bank)** [Letter must be signed by the Chief Compliance Officer or an Executive Director of the Bank] The letter must state that due KYC has been carried out and BVN requirement has been fulfilled Copy of Risk Management Policy and Technology Infrastructure **Physical copies MUST be sent to: Market Regulation Group FMDQ OTC Securities Exchange 1, Olosa Street Victoria Island Lagos Attention: Membership Management Unit Email submission of documents to be made to mmu@fmdqotc.com APPLICATION FEE PAYMENT INFORMATION Accepted Modes of Payment: Cheque/Bank Draft/Online Transfer All cheques are payable to FMDQ OTC PLC Account Details: Bank Name Access Bank PLC Account Name FMDQ OTC PLC Account Number 0689977404 Sort Code 044151106 In the case of online transfers, kindly specify payment reference in the format below: FMDQ/(Category of Membership)/(Company or Individual Name)/(Payment Date: DD.MM.YYYY) For Example: FMDQ/ASSOCIATE/OANDO/10.07.2014
APPLICANT DECLARATION By submitting this application to become a member of FMDQ OTC Securities Exchange (FMDQ) and signing this form in the manner below: We declare that the information provided is complete and accurate and we agree, if approved, to comply with and be bound by the Rules of FMDQ, which are or may be in force from time to time We further declare that we will update our trading practices in line with the Rules. We will notify FMDQ of any additional information which is relevant to the application and of any significant changes in the information provided in this application form which occur after the date of submission of the application We understand that misleading or attempting to mislead FMDQ representatives during the application process will be deemed an act of misconduct and may render the applicant liable to disciplinary proceedings We undertake to comply with FMDQ Rules, the Investment and Securities Act (ISA) 2007, SEC Rules and such other regulation relating to our activities on the FMDQ OTC Securities Exchange DIRECTOR Signature: Date: SIGNATURE DIRECTOR/SECRETARY Signature: Date: