Introducer Important Notice

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1 Introducer Important tice Please provide us with:- 1. This fully completed Application Form; 2. Copy of the Firm s Data Protection Certificate; 3. Proof of Identity & Address for each Director / Partner.

2 Introducer Application Guidance tes Please complete all sections of this form clearly. All dates should be written in the dd/mm/yyyy format. If a question is NOT APPLICABLE, please indicate clearly. Where a / answer is required, please place an X in the appropriate box. For detailed answers please use the tes page at the back of the form. Any additional information submitted with this form must be signed and dated. Any information supplied on this form will be subject to verification. If this reveals that relevant information has been omitted, either intentionally or through lack of care, or that the information is false, inaccurate or misleading, processing times will lengthen and in some cases the application may be rejected. At any time after receiving an application and before determining whether the application is to be accepted, HomeLoan Partnership may require the firm to provide further information. In all circumstances, disclosures must be full, frank and unambiguous. If you are in doubt about the relevance of any information, such information should be included. Section One Firm Details Full Name Of The Firm: Office Address Business Mobile Phone Number: Business Fax Number (including STD Code): Please provide details of an individual we can contact about any information supplied on this application form. This must be someone at the firm. Principal Contact Details: Title: Mr Mrs Miss Ms Other Surname: Forenames: Job Title: Contact Telephone Number (including STD code): Contact Address: Data Protection It is a legal requirement that all firms that hold personal details, whether written or computerised, must be registered with the Information Commissioners Office. Please enter your firm s Data Protection registration number below. Legal Status of Firm Cross one of the following to indicate the legal status of the firm Private Limited Company Public Limited Company Limited Liability Partnership Limited Partnership Partnership (other than LLP) Sole Trader Companies House Registration Number where applicable: 2

3 For Partnerships / Limited Companies Please provide details of all partners, shareholders and directors as applicable: Name Role % Shareholding (if appl.) Regulated Status Has the firm ever been registered with the FCA or previous financial services regulatory body? If yes, what is/was the Firm Reference Number (FRN)? Has the firm ever had a regulatory visit, desktop audit or any other supervision intervention? If, please supply a copy of the report or findings or any correspondence. Has the firm ever been removed from the panel of a mortgage lender, insurance provider or other financial services company? If yes, please provide details at the end of this form. Introduction Details Please indicate the name of the Appointed Representative to whom you intend to introduce business: What is the firm s main business activity? Please provide a brief indication of how you will identify potential clients suitable to be introduced? Will you be undertaking any marketing or promotional activities in relation to this introducer arrangement? (Excluding distribution of approved marketing material provided by the Appointed Representative) If yes, please provide details: Fitness & Propriety Answer the questions by crossing the relevant box. Where the answer to any of the questions is, please give complete details on the Supplementary Information Sheet. Has the firm ever been the subject of formal investigation under the powers in the Companies Act 1985? Has the firm been the subject of an application to dissolve it or to strike it off the Register of Companies? Is, or has the firm been the subject of an investigation by the FCA or any other Regulator. Has a petition for the bankruptcy or compulsory winding up of the firm ever been presented? * Has the firm had a receiver or administrator appointed, failed to satisfy a debt adjudged due, or come to a compromise or similar arrangement with any of its creditors? Has the firm been the subject of a reconstruction, whether as a result of any form of insolvency or otherwise? Has the firm had an application for an interim order made against it under section 252 of the Insolvency Act 1986 (or, in rthern Ireland, section 227 of the Insolvency [rthern Ireland] Order 1989)? Has the firm been a defendant in any criminal or civil proceedings or arbitration in the last 5 years or is any unsatisfied judgment debt or award outstanding against it? Have any settlements been entered into in the last 5 years, whether or not on an ex-gratia basis, to avoid legal action being brought against the firm or to avoid publicity? Is the firm involved as a defendant in any proceedings, investigations or other events referred to in any of the questions above which are not yet determined? Or are any such proceedings, investigations or other such events pending? 3

4 Has the firm at any time been sanctioned for fraud or other dishonesty or an offence under legislation (whether or not in the United Kingdom) relating to companies, building societies, industrial and provident societies, credit unions, friendly societies, insurance, banking or other financial services, insolvency, customer credit or consumer protection? Has the firm ever been refused, had revoked, any licence, membership, authorisation, registration or any other permission granted by a financial services regulator or any other regulated body in the UK or overseas? Are there any other significant events regarding the firm or any companies in the firm s group that might adversely affect the application?* Has the firm ceased trading in circumstances in which any of its creditors did not receive full payment? Section Two Individual Details This section should include details of any and all individuals who have a controlling interest in the firm. This must be completed by all sole traders, all partners in a partnership (whether limited or otherwise), all directors of the firm and/or any shareholders with more than 10% interest in the company. This section should be duplicated as necessary to cover additional persons. FCA Registration If you have an Individual Reference Number with the FCA, please enter it here: Personal Details: Title: Mr Mrs Miss Ms Other Surname: Date of Birth: / / Forenames: Job Title: Contact Telephone Number (including STD code): Contact Address: Mobile Phone Number: NI Number: Current Address: House Name / Number: When did you move to your current address? / / If you have lived at this address for less than 3 years, please provide previous addresses in the notes section. Employment History We need to establish a full and accurate 5 year occupation history for the introducer. Please provide details of your employment / self-employment history in reverse chronological order (i.e. most recent first). Any gaps of more than 1 calendar month should be explained. For periods of unemployment, whether claimed or unclaimed, full details need to be explained in the notes section at the back of this application. If you were in full time education please show the relevant details in this Employment History section including contact details. Current / Most Recent Employment: Dates of employment: From: / / To: / / Employed Self Employed Full-Time Education Other (Use tes section) If self-employed, please provide details of accountant or any company that you are contracted to. Firm Name: Nature of Business: Is / was the firm regulated by a regulatory body? If please state Was the firm an Appointed Representative? If, name principal Position Held: 4

5 Responsibilities: Reason for leaving: Office Address Previous Employment 1 (If less than 5 years at Current Employment) Dates of employment: From: / / To: / / Employed Self Employed Full-Time Education Other (Use tes section) If self-employed, please provide details of accountant or any company that you are contracted to. Firm Name: Nature of Business: Is / was the firm regulated by a regulatory body? If please state Was the firm an Appointed Representative? If, name principal Position Held: Responsibilities: Reason for leaving: Office Address Previous Employment 2 (If less than 5 years at Current Employment) Dates of employment: From: / / To: / / Employed Self Employed Full-Time Education Other (Use tes section) If self-employed, please provide details of accountant or any company that you are contracted to. Firm Name: Nature of Business: Is / was the firm regulated by a regulatory body? If please state Was the firm an Appointed Representative? If, name principal Position Held: Responsibilities: Reason for leaving: 5

6 Office Address Previous Employment 3 (If less than 5 years at Current Employment) Dates of employment: From: / / To: / / Employed Self Employed Full-Time Education Other (Use tes section) If self-employed, please provide details of accountant or any company that you are contracted to. Firm Name: Nature of Business: Is / was the firm regulated by a regulatory body? If please state Was the firm an Appointed Representative? If, name principal Position Held: Responsibilities: Reason for leaving: Office Address If the dates of employment do not cover the last 5 years, please provide previous employment details in the tes section. Other Business Interests Please provide details of all existing / previous authorisations or appointments held by you (eg. Directorships / Partnerships) below and provide full information in the Supplementary Information section if any of these companies have ceased to trade. Company Name Role (e.g. Director / Partner etc.) % Shareholding (if appl.) Proof of Identity and Address Please provide a photocopy of the following (tick the relevant box to confirm what is enclosed): Either:- Passport; or Photo-Card Driving Licence; And:- Utility Bill (dated within the last 3 months); or Bank Statement (dated within the last 3 months); or Council Tax Demand (most recent) 6

7 Fitness & Propriety Answer the questions by crossing the relevant box. Where the answer to any of the questions is, please give complete details on the Supplementary Information Sheet. Do you have any convictions or cautions in respect of any criminal offence of dishonesty, fraud, financial crime or violence? Spent convictions for relevant offences must be disclosed in accordance with the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 unless they are protected. Are you currently the subject of any current criminal or civil proceedings? Do you have any unspent convictions in respect of any offence under legislation relating to: a) Banking? b) Financial Services? c) Companies Act? d) Insurance? e) Consumer Protection? Are there currently any outstanding judgment debts or awards (whether in full or in part) against you? (e.g. County Court Judgments) or have you been in arrears or default with creditors during the last 2 years? Are you currently subject to any charges, civil proceedings or litigation in respect of offences under legislation relating to: a) Banking? b) Financial Services? c) Companies Act? d) Insurance? e) Consumer Protection? Have any settlements been entered into in the last 5 years, whether or not on an ex-gratia basis, to avoid legal action being brought against you or to avoid publicity? Have you or any firm of which you have been a director, partner or controller, in the last 5 years been the subject of any: a) Bankruptcy? b) Insolvency? c) Liquidation Proceedings? d) Dissolution? e) Proposal to Strike Off? Have you ever had the right to carry on any trade, business or profession for which specific licence, authorisation, registration membership or other permission is required: a) Refused? b) Restricted? c) Terminated? Are you currently the subject of any disciplinary investigation by a regulator, government body, agency, employer or other FCA authorised firm? In the past 5 years, have you been the subject of any disciplinary investigation by a regulator, government body, agency, employer or other FCA / FSA authorised firm? Have you, or any firm that you have worked for, ever been removed from a lender s panel? Have you as an individual, or a company within which you have worked and/or been authorised, ever been involved in discussions or correspondence with a regulator over any investigation or disciplinary matter or routine audit including TCF or thematic audits whether in person or desk-based telephone audit? If yes, please provide details in the Supplementary Information section. Are you, or have you ever been the subject of an investigation by the FCA, any other regulator, network or employer? Do you have any evidence of Training & Competence (including attainment of CAS if applicable) that could be provided to us? Have you an application pending for any other network or has any previous application been declined? Please confirm whether you have acted as an adviser in ANY regulated activity that is not specifically detailed on the application form? If you have answered yes to any question, please ensure you provide additional information in the tes section. 7

8 Supplmentary tes Section Please add additional information in relation to any relevant part of the application. Section te Please continue on a separate sheet if necessary Introducer Declaration I understand the scope and limitation of my appointment as an Introducer, and what constitutes an introduction. I confirm that the information supplied in this form is complete and correct to the best of my knowledge. I confirm that the information contained within this form is the basis of this application and there are no other relevant facts of which HomeLoan Partnership should be aware. I understand checks may be made to verify the answers given and authorise HomeLoan Partnership to make enquiries and seek further information deemed appropriate in processing this application and determining suitability for registration. I understand that the personal information I have provided may be disclosed to one or more licenced credit reference agencies for the purpose of allowing a search of their records to establish address(es) and other publicly available information. I understand that the credit reference agencies will keep a record of HomeLoan Partnership s enquiry. I confirm that I will notify HomeLoan Partnership if any material facts stated in this form change. The personal information provided in this form will be used by HomeLoan Partnership or its designated Appointed Representative to discharge its obligations as a Principal Network as defined by the Financial Conduct Authority and other relevant legislation. It will not be disclosed for any other purpose without the permission of the applicant. Signature: Date: Print Name: Position in Company: As an introducer to HomeLoan Partnership you will receive regular communications regarding regulatory requirements and activities. We may, from time to time, make your details available to carefully screened companies who are all service providers to HomeLoan Partnership. Please indicate if you would prefer not to receive that information. Please ensure you have enclosed a copy of the Data Protection Certificate with this application. 8

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