Annex to Notice No. 4/2014 of the Bank of Cape Verde

Questionnaire on Professional Qualification, Suitability and Availability of Members of the Administrative or Supervisory Body of Financial Institutions

1. Request Framework

Full Name: [Blank] Initial Application | Record Amendment | Record Renewal

2. Personal Information

Change in personal data? Yes | No Professional Name: [Blank] | Date of Birth: [Blank] | Parish (Freguesia): [Blank] Municipality (Concelho): [Blank] | Country: [Blank] | Nationality: [Blank] Identification Document: [Blank] | Personal Residence: [Blank] Phone: [Blank] | Email: [Blank]

3. Professional Status

Change in previously submitted data? Yes | No Professional activity to be performed subject to registration with the Bank of Cape Verde Entity: [Blank] | Sector/Activity Branch: [Blank] | Position: [Blank] Date of Appointment: [Blank] | Term Duration: [Blank] | Portfolio/Area (Pelouro): [Blank] Executive Functions? Yes | No | Current Management? Yes | No Relationship between this entity and others where you hold functions: [Blank]

Professional activity already registered with the Bank of Cape Verde, to be performed in accumulation with the currently subject-to-registration activity Entity: [Blank] | Sector/Activity Branch: [Blank] | Position: [Blank] Date of Appointment: [Blank] | Term Duration: [Blank] | Portfolio/Area (Pelouro): [Blank] Executive Functions? Yes | No | Current Management? Yes | No Relationship between this entity and others where you hold functions: [Blank]

Professional activity not subject to registration with the Bank of Cape Verde, to be performed in accumulation with the currently subject-to-registration activity Entity: [Blank] | Sector/Activity Branch: [Blank] | Position: [Blank] Date of Appointment: [Blank] | Term Duration: [Blank] | Portfolio/Area (Pelouro): [Blank] Executive Functions? Yes | No | Current Management? Yes | No Relationship between this entity and others where you hold functions: [Blank]

4. Professional Qualification

Change in previously submitted data? Yes | No Academic Qualifications Training/Course | Educational/Training Institution | Year Obtained [Blank]

Professional experience performed in the last 10 years relevant to the role Entity | Sector/Activity Branch | Functions | Period of Exercise of Functions [Blank]

5. Suitability

Change in previously submitted data? Yes | No

• Have you ever been convicted in Cape Verde or abroad in criminal proceedings? (Yes | No)
• Are there any pending criminal proceedings against you in a court in Cape Verde or abroad? (Yes | No)
• Have you ever been fined in Cape Verde or abroad in administrative offence proceedings for facts related to the exercise of your professional activities in the financial sector? (Yes | No)
• Have you ever been compulsorily removed from your position in a financial institution or analogous entity by a decision of a national or foreign supervisory authority, analogous to the Bank of Cape Verde? (Yes | No)
• Are there any pending administrative offence proceedings against you before an administrative authority in Cape Verde or abroad for facts related to the exercise of your professional activities in the financial sector? (Yes | No)
• Have you ever been charged in administrative offence proceedings brought by the Bank of Cape Verde or a national or foreign supervisory entity analogous to the Bank of Cape Verde? (Yes | No)
• Have you ever been charged in administrative offence proceedings brought by the Bank of Cape Verde against a company controlled by you or in which you held administrative or supervisory functions? (Yes | No)
• Have you ever been convicted in Cape Verde or abroad for a company controlled by you or in which you held administrative or supervisory functions, due to breaches of legal or regulatory rules governing the activity of financial institutions or other entities supervised by the Bank of Cape Verde? (Yes | No)
• Have you ever been declared bankrupt in Cape Verde or abroad? (Yes | No)
• Have you ever been declared bankrupt in Cape Verde or abroad for a company controlled by you or of which you were a member of the administrative or supervisory body? (Yes | No)
• Are there any pending bankruptcy proceedings against you in Cape Verde or abroad? (Yes | No)
• Are there any pending bankruptcy proceedings concerning companies controlled or previously controlled by you, or in which you hold or have held administrative or supervisory functions? (Yes | No)
• Have you ever been sanctioned in disciplinary proceedings in Cape Verde or abroad? (Yes | No)
• Have you ever been subject to a sanction for violation of conduct rules applicable to the exercise of professional activity? (Yes | No)
• Have you ever been refused, in Cape Verde or abroad, by the competent supervisory authorities, the registration necessary to exercise functions in a financial institution or analogous entity? (Yes | No)
• Have you ever, in Cape Verde or abroad, had the competent authorities object to your acquisition or maintenance of a qualifying holding in a financial institution or analogous entity? (Yes | No)

6. Independence and Incompatibilities – Members of the Supervisory Body

• Do you hold or have you held administrative functions in the financial institution during the last two years? (Yes | No)
• Are you a member of any corporate bodies of a company in a relationship of control or group with the financial institution? (Yes | No)
• Do you provide paid services on a permanent basis to the financial institution or company(ies) in a relationship of control with it? (Yes | No)
• Do you hold functions in a company competing with the financial institution? (Yes | No)
• Are you a spouse, relative or affine in direct line or collateral line up to the third degree, inclusive, of the persons indicated in letters a), b) and c) of Article 441(3) of the Commercial Companies Code? (Yes | No)
• Do you hold or act in the name of or on behalf of holders of a qualifying holding equal to or greater than 2% of the capital of the financial institution? (Yes | No)
• Are you associated with any specific interest groups in the company? (Yes | No)
• Have you been re-elected for more than two terms to the bodies of the financial institution? (Yes | No)
• Do you benefit or have benefited from particular advantages of the financial institution? (Yes | No)
• Do you hold administrative or supervisory functions in five or more companies? (Yes | No)

The undersigned declares, under oath of honor, that the information provided above corresponds to the truth and has not omitted any facts relevant to their registration. Furthermore, they declare that they are aware that providing false statements constitutes grounds for refusal or cancellation of registration, without prejudice to the eventual application of criminal or administrative offence sanctions. They further undertake to notify the Bank of Cape Verde, within fifteen days from when the facts occur, all facts likely to modify any of the answers given in this questionnaire.

Date:_______//
Signature:__________________________________________________________________________
(Notarially acknowledged)