Bank of Mauritius Fit and Proper Person Questionnaire Annexure

BOM/BSD 11/Form 1/October 2003
Revised: January 2014
June 2014
September 2016
FOR ASSESSING THE FITNESS AND PROBITY OF PERSONS WITH MATERIAL INFLUENCE ON THE OPERATION AND AFFAIRS OF BANKS, NON-BANK DEPOSIT TAKING INSTITUTIONS AND CASH DEALERS. (Please specify ‘NA’ where information requirement is not applicable) PURPOSE OF ASSESSMENT PROPOSED POSITION INSTITUTION TYPE OF DIRECTORSHIP, IF APPLICABLE (whether Independent, Executive or Non-Executive) PERSONAL DETAILS FAMILY NAME FIRST NAME DATE OF BIRTH (DD/MM/YYYY) PLACE OF BIRTH (TOWN AND COUNTRY) NATIONALITY HOW NATIONALITY WAS ACQUIRED? Birth □ Naturalisation □ Marriage □ GENDER MARITAL STATUS Male □ Female □ Single □ Married □ Divorced □ ID NUMBER PASSPORT NUMBER CURRENT POSTAL ADDRESS CURRENT RESIDENTIAL ADDRESS (if different from current postal address) PERMANENT ADDRESS (if different from current residential address) TELEPHONE NUMBER Residential Business FAX NUMBER EMAIL ADDRESS ADDITIONAL DETAILS HAVE YOU EVER BEEN SUBJECT TO A CHANGE OF NAME (if ‘Yes’ provide full details below) YES □ NO □ PREVIOUS FAMILY NAME PREVIOUS NAME DATE OF CHANGE REASONS FOR CHANGE Bank of Mauritius Fit and Proper Person Questionnaire Annexure

HAVE YOU CHANGED YOUR PERMANENT ADDRESS DURING THE LAST TEN YEARS (if ‘Yes’ provide full details below) YES □ NO □ FULL PREVIOUS PERMANENT ADDRESS DATE OF CHANGE ACADEMIC QUALIFICATIONS QUALIFICATION AND YEAR EXAMINING BODY GRADE PROFESSIONAL QUALIFICATIONS PROFESSIONAL BODY STATUS DATE OF ADMISSION PROPOSED RESPONSIBILITIES (Please provide full details of your proposed duties and responsibilities)

EMPLOYMENT HISTORY COVERING AT LEAST THE TEN PREVIOUS YEARS (start with current and most recent position) 1 EMPLOYER’S NAME NATURE OF EMPLOYER’S BUSINESS EMPLOYER’S ADDRESS EMPLOYER’S PHONE NUMBER EMPLOYER’S FAX NUMBER EMPLOYER’S EMAIL YOUR JOB TITLE BRIEF DESCRIPTION OF DUTIES AND RESPONSIBILITIES DATE OF APPOINTMENT DATE OF RESIGNATION REASONS FOR RESIGNATION 2 EMPLOYER’S NAME NATURE OF EMPLOYER’S BUSINESS EMPLOYER’S ADDRESS EMPLOYER’S PHONE NUMBER EMPLOYER’S FAX NUMBER EMPLOYER’S EMAIL YOUR JOB TITLE BRIEF DESCRIPTION OF DUTIES AND RESPONSIBILITIES DATE OF APPOINTMENT DATE OF RESIGNATION REASONS FOR RESIGNATION 3 EMPLOYER’S NAME NATURE OF EMPLOYER’S BUSINESS EMPLOYER’S ADDRESS EMPLOYER’S PHONE NUMBER EMPLOYER’S FAX NUMBER EMPLOYER’S EMAIL YOUR JOB TITLE BRIEF DESCRIPTION OF DUTIES AND RESPONSIBILITIES DATE OF APPOINTMENT DATE OF RESIGNATION REASONS FOR RESIGNATION

SHAREHOLDINGS* OF 50 PER CENT AND ABOVE (INCLUDING INDIRECT HOLDINGS) HISTORY OVER AT LEAST THE LAST TEN YEARS NAME OF ENTITY DATE INFLUENCE WAS ACQUIRED DATE INFLUENCE WAS RELINQUISHED OTHER SHAREHOLDINGS* (INCLUDING INDIRECT HOLDINGS) HELD CURRENTLY NAME OF ENTITY DATE ACQUIRED NUMBER OF SHARES HELD DIRECTORSHIP HISTORY OVER AT LEAST THE LAST TEN YEARS NAME OF ENTITY DATE OF APPOINTMENT DATE OF RESIGNATION *Includes shareholdings held in local and overseas entities

SPECIFIC TEST TO ASSESS FITNESS AND PROBITY YES NO REF.

Have you ever been subject to any proceedings of a disciplinary or criminal
nature, or have been notified of any impending proceedings or of any investigation, which might lead to such proceedings? □ □ ……….
Have you, or any business in which you have had controlling interest or
have exercised significant influence, been investigated, disciplined, suspended or criticised by a regulatory or professional body, a court or tribunal, whether publicly or privately?

□ ……….

Have you ever been associated, in ownership or management capacity, with
a company, partnership or other business association that has been refused registration, authorisation, membership or a licence to conduct trade, business or profession, or has had that registration, authorisation, membership or licence revoked, withdrawn or terminated?

□ ……….

As a result of the removal of the relevant licence, registration or other
authority mentioned in question 3 above, have you ever been refused the right to carry on a trade, business or profession requiring a licence, registration or other authorisation?

□ ……….

Have you ever been subject of any justified complaint relating to regulated
activities? □ □ ……….
Have you ever been charged or convicted of any criminal offence,
particularly an offence relating to dishonesty, fraud, financial crime or other criminal acts or been involved in acts of misfeasance or serious misconduct?

□ ……….

Have you ever contravened any of the requirements and standards of a
regulatory body, professional body, government or its agencies? □ □ ……….
Have you ever been a director, partner, or otherwise involved in the
management, of a business that has gone into receivership, insolvency or liquidation while you have been connected with that business or within one year after that connection?

□ ……….

Have you ever been dismissed, asked to resign or resigned, from
employment or from a position of trust, fiduciary appointment or similar because of questions about your honesty and integrity?

□ ……….

Have you ever been disqualified, under the Companies legislation or any
other legislation or regulation from acting as a director or serving in a managerial capacity?

□ ……….

Have you ever been diagnosed as being mentally ill or unstable? □ □ ……….
Have you ever been disciplined by a professional, trade or regulatory body;
or dismissed or requested to resign from any position or office for negligence, incompetence or mismanagement?

□ ……….

Have you ever been the subject of any adverse judgment or award, in
Mauritius or elsewhere that remains outstanding or was not satisfied within a reasonable period?

□ ………..

Have you ever made any arrangements or composition with your creditors,
filed for bankruptcy, been adjudged bankrupt, had your assets sequestrated, or been involved in proceedings relating to any of these?
Do you hold any directorship in any company related to the financial
institution*?
Do you have any relationship with the financial institution* or its affiliates?
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SPECIFIC TEST TO ASSESS FITNESS AND PROBITY (Cont’d) YES NO REF.
17. Have you ever been a senior officer of a company or a shareholder in a
position to exercise significant influence in the company that:
a. has been the subject of any adverse judgment or award, in Mauritius or elsewhere, that remains outstanding or was not satisfied within a reasonable period; b. has, in Mauritius or elsewhere, made any arrangements or composition with its creditors, filed for bankruptcy, been adjudged bankrupt, had assets sequestrated, or been involved in proceedings relating to any of the foregoing? □ □ □

………..
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Do you have reasons to believe that any of your close relatives or business
associates, if subject to the above tests, would have responded by a ‘Yes’ to any of the above questions?

□ ………..

Do you have any liability towards
a. the financial institution*? b. any other financial institution? If the answer to a. or b. is ‘YES’, please state whether any of them is in default. □ □ □ □ □

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Do you have any interest in the financial institution*? □ □ ……….
IF THE ANSWER TO ANY OF THESE QUESTIONS IS ‘YES’ PLEASE PROVIDE DETAILS ON SEPARATE PAGES WITH PROPER REFERENCING

refers to the financial institution where you are an employee or a director or hold significant interest or are
being offered employment or directorship or significant interest. SIGNATURE AND ACKNOWLEDGEMENT I hereby declare that:
a. to the best of my knowledge and belief the statement made and the information supplied in this questionnaire and the attachments are correct and that there are no other facts that is relevant to the board of directors for assessing my fitness and probity; b. I understand that the board of directors may seek additional information from any third parties it deems necessary in view of assessing my fitness and probity;
c. I undertake to bring to the attention of the board of directors any matter which may potentially affect
my status as being someone fit and proper as and when they crop up; and d. if I am appointed as an independent director, I confirm that I have no relationship with, or interest in, whether past or present, the financial institution or its affiliates, which could or could reasonably be perceived to materially affect the exercise of my judgment in the best interest of the financial institution. Signature: __________________________ Date: ________________________ AUTHORISATION TO ACCESS MCIB I hereby authorise the Bank of Mauritius to access my credit profile on the Mauritius Credit Information Bureau. Signature: __________________________ Date: ________________________ INFORMATION PROVIDED ON SEPARATE PAGES SHOULD BE DULY SIGNED AND DATED.

Bank of Mauritius Fit and Proper Person Questionnaire Annexure

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