Licenceholder Contact Sheet

Licenceholder Contact Details This form is for use by Financial Services Act 2008 licenceholders only LICENCEHOLDER NAME FSA Reference Please indicate if the details on form relates to all classes of licence or a specific class only. Applicable to all classes of licence held Yes No Only applicable to Class(es): General Correspondence Details (Public Information) Address Details: This should be the address to which all Licenceholder correspondence is to be sent Telephone Number: Fax Number: Email Address: Website Address: FSA Primary Contact Details Note: The Primary Contact will be the only recipient of mail merges (letter or email) sent by the FSA. Letters will be sent to the General Correspondence address given above. Contact Name & Title: Position: Telephone Number: Fax Number: Email Address: Financial Reporting System (”FRS”) –Contact Details Note: For completion where the Licenceholder uses the FRS to provide interim financial returns. The FRS contact will only be contacted in connection with the FRS. Contact Name & Title: Position: Telephone Number: Fax Number: Email Address: Date of Completion: Completed by: Position within Licenceholder: Signature (On behalf of the above named Licenceholder):

For FSA Use Only (September 2018 Version) Input By – Date and Initials Checked by – Date and Initials Supervision Records updated Finance Advised IT Advised (FRS user only) 🔒 Data Protection Notice The Authority is registered with the Information Commissioner as a data controller under Isle of Man data protection legislation. The Authority collects and processes personal data to carry out its functions under relevant legislation and may share personal data with other parties where there is a legal basis for doing so. Information on how the Authority collects and processes personal data can be found in the Privacy Policy on the Authority’s website: https://www.iomfsa.im/terms-conditions/privacy-policy/ Please call +44 (0)1624 646000 if you have any queries.