Application for the Approval of Compliance Officers

APPLICATION FOR THE APPROVAL OF COMPLIANCE OFFICERS In accordance with Section 4(2) of the Financial Obligations Regulations, 2010. First Name: Middle Name: Surname: FOR TTSEC OFFICIAL USE Country of birth: ONLY Identification No.(please provide at least 2 forms)  Passport __________________________________  National Identification________________________  Drivers Permit ______________________________  Other _____________________________________ Please Specify_________________________________ Country/Countries of Citizenship: Date of birth: DD/MM/YYYY Email: Residential Address: Contact #: Fax: Work: Home: Mobile: Highest Level of education: Eg. Secondary, tertiary, undergraduate etc. Mailing Address (If different from above): Professional qualification or membership: Have you ever had a change of name? (If yes, please give details) Name of Employer : Annual Renewal Date of Employer’s Registration with TTSEC: Category of Registration(s) employer holds with TTSEC: Position held with above registered entity:

1. Have you ever been convicted of an offence in Trinidad and Tobago or elsewhere? If yes, please give particulars. YES NO
2. Are there any criminal proceedings pending against you in Trinidad and Tobago or elsewhere? If yes, please give particulars YES NO
3. Have any civil or administrative fines or sanctions been imposed upon you? If yes, please give particulars. YES NO
4. Have you at anytime failed to satisfy a judgment debt under a Court Order made in Trinidad and Tobago or anywhere else? If yes, please give particulars. YES NO
5. Have you at any time, in Trinidad and Tobago or anywhere else been declared bankrupt or are you the subject of any bankruptcy proceedings? If yes, please give particulars. YES NO

I hereby certify that the information contained in this application form and all appendices hereto attached are true and accurate to the best of my knowledge and belief.

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DATE SIGNATURE OF APPLICANT PRINT NAME

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DATE SIGNATURE OF CEO PRINT NAME

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DATE SIGNATURE OF MANAGING DIRECTOR PRINT NAME 6. Are you currently a Director of any company? If yes, provide the name of the company, date and place of incorporation and the date of your appointment. YES NO 7. Have you held a senior position in a company that has gone into liquidation/ receivership within the past five (5) years? If yes, please give particulars. YES NO 8. Have you ever been a senior officer of an entity in Trinidad and Tobago or elsewhere, that was, during your period of association, convicted of an offence? If yes, please give particulars. YES NO 9. Have you ever been disqualified or restricted in Trinidad and Tobago or elsewhere by a court from acting as a director of a company? If yes, please give particulars. YES NO 10. Have you ever been dismissed or compelled to resign from any office or Employment? If yes, please give particulars. YES NO 11. Have you ever been refused entry to any professional membership/institution? If yes, please give particulars. YES NO 12. Have you ever received or been exposed to any AML/CFT or compliance training? If yes, please give particulars. YES NO 13. Have you ever been registered in any capacity under the securities law of Trinidad and Tobago or another jurisdiction? If yes, please give particulars YES NO 14. Has any registration identified at item 13 above been suspended, revoked, or allowed to expire? If yes, please give particulars YES NO 15. Is there any other information that you consider relevant to this application? If yes, please give particular. YES NO

APPLICATION FOR THE APPROVAL OF COMPLIANCE OFFICERS In accordance with Section 4(2) of the Financial Obligations Regulations, 2010. Please submit the following together with this application form: -Certified copies of all academic certificates (Bachelor’s degree or higher) -Certified copies of all professional qualifications or certifications

• A current Curriculum Vitae detailing your employment history
• Certified copies of two forms of identification
• Two (2) passport size photos
• Police Certificate of Character NB. -Details relevant to questions 1-15 can be provided on an additional sheet. -For the purpose of this application, a ‘Certified Copy’ is a photocopy of a document that is signed and attested to as an accurate and a complete reproduction of the original document by a Notary Public or Commissioner of Affidavits. In the alternative, original documents together with photocopies can be brought to the Commission for certification by the Staff.