Application Form for Acquisition of Substantial Interest in a Bureau de Change

APPLICATION FORM FOR ACQUISITION OF SUBSTANTIAL INTEREST1 IN A BUREAU DE CHANGE
1.0 Name of Bureau de Change ……………………………………………………
2.0 Name of the applicant…………………………………………………………...
3.0 Identification of the applicant……………………………………………………
4.0 Date of the proposed acquisition…………………………………………………
5.0 Please provide the following information on a seperate sheet of paper:
5.1 Number and type of shares now held by the applicant; number and type of
shares to be acquired and purchase price per share.
5.2 The total number of shares currently held by each transferor; the total number of
shares to be transferred.
5.3 State the reason(s) for the proposed acquisition.
6.0 Curriculum Vitae of the applicant or director(s) of the applicant if the proposed
acquirer is a body corporate.
(Including the name, address, age, occupation, nationality, academic background, working experience, the name and contact details of three referees of which one shall be financial in nature and directorship in other companies)
7.0 State whether the applicant or any director(s) of the applicant if the proposed
acquirer is a body corporate has ever been convicted in a court of law for an offence involving fraud, dishonesty or has ever been under investigation for any professional negligence or malpractice by any regulatory authority in any country.
8.0 Please provide any other information which may be of assistance when
considering this application.

As per section 2 of the Financial Institutions Act (FIA) 2004, means holding individually or together with a close relation, directly or indirectly, 10 percent or more of the capital or of the voting rights of a company or undertaking or, directly or indirectly, exercising such significant influence over the management of the company or undertaking as the Central Bank may determine.

Please note that CBS may require the submission of additional information should the need arise. We declare that the information supplied in the application is complete and correct to the best of our knowledge at the time of this declaration. Name of Applicant Signature Date

Name of Applicant
Signature
Date