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| PREVIOUS NAMES (IF ANY): | |
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| ALIASES: | | DATE OF BIRTH: | |
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| CITIZENSHIP: | |
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| PLACE OF BIRTH: | |
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| NATIONAL INSURANCE NUMBER: | |
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| ADDRESS (Home & Business): | |
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| OCCUPATION: | |
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| 1. | Have you at any time been charged or convicted of any offence by a civil, criminal or military court? (excluding minor Road Traffic offences). If so, please give details of charge, and if convicted, the date of conviction and full particulars of the offence and the penalty imposed. |
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| 2. | Have you ever been the subject of investigation/disciplinary procedures, censured, disciplined by any professional body to which you belong or have belonged? If so, give particulars. |
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| 3. | Have you ever been refused entry to any profession or vocation? If so, give particulars. |
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| 4. | Have you ever been dismissed or requested to resign from any office or employment? If so, give particulars. |
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| 5. | Have you ever been censured, disciplined by, or made the subject of a court order at the instigation of— |
| (a) | any regulatory authority? |
| (b) | any officially appointed enquiry? |
| (c) | any other established body concerned with the regulation of a relevant activity (as described in the glossary at the end of this form) ? |
| If so, give particulars. |
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| 6. | In connection with the formation or management of any corporation, have you been adjudged by a court civilly or criminally liable for any fraud, misfeasance or other misconduct towards that corporation or any member of the corporation? If so, give particulars. |
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| 7. | In connection with the formation or management of any corporation have you been disqualified by a court from being a director or from acting in the management or conduct of the affairs of any corporation? If so, give particulars. |
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| 8. | Have you ever— |
| (a) | been adjudged bankrupt by a court in any jurisdiction? |
| (b) | had a receiving order made against you? |
| (c) | had your estate sequestrated? |
| (d) | entered into a deed of arrangement, or other composition or arrangement with your creditors? If so, give particulars. |
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| 9. | Has a bankruptcy petition ever been served on you? If pending, give details of the circumstances and if not pending, how was the matter resolved? |
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| 10. | Have you, your company or your employer, previously dealt on a regular basis with any person carrying on a relevant activity* who has, to your knowledge at any time, indicated that he is unwilling to effect further transactions with you, your company or your employer, by reason of any act or omission by you? If so, give particulars. |
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| 11. | Will you be actively engaged in the business or the entity to which this application relates and devote the major portion of your time to it? |
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