First Schedule – License Application and Declaration

License application and declaration
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FIRST SCHEDULE
License application and declaration
(CBS/LCR/REG/03 Article 5)
Please place applicant’s letter head
From:
Name:
Title:
Address:
Date:
To:
Director – Licensing and Supervision Department Central Bank of Somalia Mogadishu, Somalia NON-DEPOSITORY MICROFINANCE INSTITUTION LICENSE APPLICATION We, the undersigned, do hereby apply for a license for the following applicant to engage in a non – deposit taking microfinance institution:
Name of Applicant business/partnership/entity:
We declare that to the best of our knowledge and belief, the:
a) Facts stated in this license application package are complete and correct; b) The checklist has been initialed to indicate inclusion of information and documents with this application; c) The Applicant is under investigation by any law enforcement agency Yes: No:
d) Applicant has a compliance regime in place to make sure that the non-deposit taking microfinance institution for all of licensing, regulatory reporting, record keeping, customer identification, and risk management obligations and that operational manuals are documented, written down, monitored and kept up to date; and e) Applicant understands, measures, monitors and controls the risks assumed from its non-deposit taking institution; and has adopted effective risk management practices whose sophistication are commensurate to the risks being monitored and controlled; and maintain capital commensurate with the risk exposures assumed. We fully understand that false or fraudulent statements, other material irregularities or failure to disclose accurate information may render the application liable to be denied. We also understand that if such irregularities are discovered subsequent to the issuance of the license, the Central Bank may revoke or vary the terms and conditions of the license. We understand and accept that the Central Bank may wish to investigate the application – both now and on a continuing basis – to satisfy itself of the initial and continuing financial condition and responsibility, financial and business experience, character, and general fitness and propriety of the applicant. Accordingly, we authorize the Central Bank to make such enquiries

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2 and seek such further information as it thinks appropriate in verifying the information given in this application or in other documents submitted as part of this application, for the purpose of performing its due diligence and background checks. To be valid, this application must be authorized by the Applicant’s supreme management body or the chairman of the board of directors, CEO, or any other delegated person. 1st Person Signature:…………………………………….. Full name:
2nd Person
Signature:…………………………………….
Full name:
Position:
Date:
Position:
Date: