Appointed Representative & Company Representative Application Form

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1 Appointed Representative & Company Representative Application Form IMPORTANT CHECKLIST: In addition to your fully completed application form, please can you tick the boxes below to indicate that you have: Enclosed a copy of your FCA Consumer Credit Permissions Enclosed a copy of your Data Protection Registration (DPA) Enclosed copies of Qualification Certificates for Advisers Completed the appropriate attached Direct Debit Instruction Enclosed a copy of a credit report for each individual ( Enclosed certified proof of ID and proof of address for each Individual/Controller For office use only: BDM/Introducing source Payment Terms FIRM DETAILS Full name of business and any trading styles Type of business Partnership Limited Company Limited Liability Partnership Sole Trader Other (Please specify) Number of years trading (If a new firm, please give your experience and rationale for starting the firm. Please use additional info section.) Contact address Contact name Telephone number Fax number address Website address Companies House details (If applicable, e.g. for limited companies and limited liability partnerships only) Date of incorporation County of incorporation Registration number FCA firm reference number Telephone: Website: 01

2 Please list below ALL controllers and directors of the firm. Somebody that owns 10% or greater of the company are automatically controllers, including Company Secretary. Full name % of share holding (if applicable) Full name % of share holding (if applicable) Full name % of share holding (if applicable) Full name % of share holding (if applicable) Has the applicant firm ever held any licence or authorisation at any time under: (IF YES, PLEASE PROVIDE DETAILS IN THE ADDITIONAL INFO SECTION). Where a reference to an act of parliament or any regulatory body this includes anything that supersedes, replaces or is in addition to. The Prevention of Fraud (Investments) Act 1958 or the Prevention of Fraud (Investments) Act (Northern Ireland) 1940? Yes No The Consumer Credit Act of 1974? Yes No The Insurance Brokers (Registration) Act 1977? Yes No Has the applicant firm ever been a member of, authorised or registered by the Financial Conduct Authority (FCA), any Recognised Self-Regulating Organisation, any voluntary regulator or any Recognised Professional Body (currently or previously)? (Please provide full information in the additional information section). Yes No Has the applicant firm ever had: Any licence held under the Statutes? Yes No Membership of any association of dealers in securities, any stock exchange or other professional body? Yes No Membership or any Authorisation to carry out insurance, investment or banking business, refused, revoked or withdrawn? Yes No Has the applicant firm ever resigned from or discontinued an application for membership or authorisation to any of the bodies mentioned? Yes No (Although the information requested relates to UK provisions, details of comparable overseas provisions should also be supplied). Disciplinary proceedings Has the applicant firm ever been the subject of, or interviewed in the course of, any existing or previous investigation or disciplinary proceedings, by the FCA, by other regulatory authorities (including a previous regulator), clearing house and exchanges, professional bodies or government agencies? Yes No Is the applicant firm currently the subject of any disciplinary proceedings or is it aware that such proceedings are pending? Yes No Has the applicant firm ever been the subject of a formal investigation under the powers set out in: The Insurance Companies Act1982? Yes No The Companies Act1985? Yes No The Financial Services Act1986? Yes No The Financial Services & Markets Act 2000? Yes No Telephone: Website: 02

3 Criminal or civil proceedings Has the applicant firm ever been a defendant in any civil proceedings, or party to any arbitration, in relation to any investment business or other financial business (i.e. mortgage related matters) or been charged or convicted under the Theft Act or been the subject of any other criminal proceedings? Yes No Judgments & debts - has the firm ever: Had a petition presented or a meeting summons to consider a resolution, to wind up the organisation or has the organisation wound up? Yes No Had its estate sequestered, or is the organisation currently the subject of proceedings or are you aware of any proceedings for the sequestration of its estate? Yes No Had a receiver, administrative receiver or administrator appointed in respect of the whole or any part of its property? Yes No Had an administrator, receiver, or trustee appointed or an application made for such an appointment? Yes No Made a composition or arrangement with one or more of its creditors, or made proposals for such? Yes No Ceased trading in circumstances in which any of its creditors did not receive full payment? Yes No Had any judgment debt entered against it? Yes No Been struck off the register by the Registrar of Companies? Yes No Been convicted by a court (whether magistrates,crown or military) for any offence? Yes No Been subject to penalties for tax evasion or an investigation conducted by the tax authorities? Yes No Been adjudged by a court liable for any fraud,wrongful trading or other misconduct? Yes No Had any associated business (whether or not connected with the Financial Services Industry) Yes No If yes please give details in the space provided. Will any of these businesses conflict with your Financial Services Business? Yes No If yes please give details in the space provided. Been or previously been, authorised under the Financial Services & Markets Act 2000? Yes No If yes please give details in the space provided. PERSONAL DETAILS (This section must be completed by ALL controllers and advisers) Title Surname Forename Middle Name(s) Date of birth Place of birth NI Number Home Address If less than 3 years at this address please provide full address history for the last 3 years in additional information section on pages 9 and 10. This is a mandatory requirement. Daytime tel no Daytime fax no address 03

4 PERMISSIONS REQUIRED Please indicate which permissions you require: Mortgages (Standard) Mortgages (Standard) Mortgages (Standard) Mortgages (Standard) Mortgages (Equity Release) Mortgages (Equity Release) Mortgages (Equity Release) Mortgages (Equity Release) Non-Investment Insurance Non-Investment Insurance Non-Investment Insurance Non-Investment Insurance Please give details of experience in each area you are applying for (in years): Mortgages (Standard) Mortgages (Standard) Mortgages (Standard) Mortgages (Standard) Mortgages (Equity Release) Mortgages (Equity Release) Mortgages (Equity Release) Mortgages (Equity Release) Non-Investment Insurance Non-Investment Insurance Non-Investment Insurance Non-Investment Insurance Please confirm the total number of cases written over the last 12 months: Mortgages (Standard) Mortgages (Standard) Mortgages (Standard) Mortgages (Standard) Mortgages (Equity Release) Mortgages (Equity Release) Mortgages (Equity Release) Mortgages (Equity Release) Non-Investment Insurance Non-Investment Insurance Non-Investment Insurance Non-Investment Insurance QUALIFICATIONS Please indicate your qualifications as below (please enclose certified copies of certificates): FPC Part 1 FPC Part 1 FPC Part 1 FPC Part 1 FPC Part 2 FPC Part 2 FPC Part 2 FPC Part 2 FPC Part 3 FPC Part 3 FPC Part 3 FPC Part 3 Full Full Full Full FPC + bridge paper FPC + bridge paper FPC + bridge paper FPC + bridge paper CeMap Part 1 CeMap Part 1 CeMap Part 1 CeMap Part 1 CeMap Part 2 CeMap Part 2 CeMap Part 2 CeMap Part 2 CeMap Part 3 CeMap Part 3 CeMap Part 3 CeMap Part 3 CeFA 1 CeFA 1 CeFA 1 CeFA 1 CeFA 2 CeFA 2 CeFA 2 CeFA 2 CeFA 3 CeFA 3 CeFA 3 CeFA 3 CeFA 4 CeFA 4 CeFA 4 CeFA 4 CF1 CF1 CF1 CF1 CF2 CF2 CF2 CF2 CF3 CF3 CF3 CF3 CF4 CF4 CF4 CF4 CF5 CF5 CF5 CF5 CF6 CF6 CF6 CF6 Other (please state) Other (please state) Other (please state) Other (please state) 04

5 FITNESS & PROPRIETY This section must be completed by ALL individuals. (IF YOU ANSWER YES TO ANY OF THESE, PLEASE PROVIDE ADDITIONAL INFORMATION AT THE END OF THIS FORM) Have you,or a firm that you have been associated with had a lender or insurer agency withdrawn or terminated? Have you ever had any convictions in respect of any criminal offence of dishonesty, fraud financial crime or violence? Have you ever had any convictions in respect of any offence under legislation relating to: Banking Financial Services Companies Insurance Are you currently subject to any criminal charges in respect of any criminal offence of dishonesty, fraud, financial crime or violence? Are you currently subject to any charges, civil proceedings or litigation in respect of offences under legislation relating to: Banking Financial Services Companies Insurance Are there currently any outstanding judgement debts or awards (whether in full or in part) against you? Have you ever been the subject of a bankruptcy petition, county court judgement, an insolvency petition, an application to dissolve, the appointment of a receiver, administrator or trustee or entered into a composition or agreement with creditors? Have you ever defaulted on a mortgage, loan or other credit agreement? Have you previously held a senior position in a firm that: Has been rejected for registration with the FCA or any other regulator? Had sanctions imposed by an FCA disciplinary committee or any other regulator? Is currently subject to disciplinary procedures? Has voluntarily deregistered from the FCA or any other regulator, or allowed their registration to lapse? Have you, or any firm of which you have been a director, partner or controller, in the last three years been the subject of any: Bankruptcy Insolvency Liquidation proceedings Please provide details of all existing authorisations or approvals held by you in the financial services sector: Telephone: Website: 05

6 Have you ever had the right to conduct any trade, business or profession for which a specific licence, authorisation, registration, membership or permission is required, and had it: Refused Restricted Terminated Have you ever been or are you currently the subject of any disciplinary investigation by a regulator or government body or agency? In the past 5 years, have you been a director, partner or controller of any financial services sector business that has: Ceased to trade Become insolvent Gone into liquidation Had an administrator appointed If YES to any of the above questions, please include a seperate sheet with a full explanation and any supporting documentation. Have you received any complaints in the last 5 years? Please state how many were upheld providing details of compensation paid and supporting documentation where necessary. EMPLOYMENT DETAILS Please provide employment details to cover the last 10 years. If there are more than 4 individuals within your firm, or you need additional space, please photocopy this page. Current Employment Start date of employment What is your employment status? Employed Employed Employed Employed Self-employed Self-employed Self-employed Self-employed Unemployed Unemployed Unemployed Unemployed Full Time Education Full Time Education Full Time Education Full Time Education What is your job role: Director/Controller Director/Controller Director/Controller Director/Controller Mortgage/Insurance Advisor Mortgage/Insurance Advisor Mortgage/Insurance Advisor Mortgage/Insurance Advisor If you are currently an Appointed Representative of an FCA authorised firm, please state: Name of current firm FCA firm reference number (FRN) (if applicable) Address of current employer Telephone: Website: 06

7 Are you a member of a Network? If yes please state name of Network If you have previously been approved by the FCA, please state your FCA Individual Reference Number DO YOU CONSENT TO APPROACHING THIS EMPLOYER? Previous Employment Start date of employment End date of employment Were/are you? Employed Employed Employed Employed Self-employed Self-employed Self-employed Self-employed Unemployed Unemployed Unemployed Unemployed Full Time Education Full Time Education Full Time Education Full Time Education Name of firm Was the firm FCA Authorised or a member of a network? DO YOU CONSENT TO APPROACHING THIS EMPLOYER? Yes No Yes No Yes No Yes No If yes state network/fca No. Nature of business Address Postcode Is/Was the firm regulated by a body? If yes state name of body Reason for leaving Telephone: Website: 07

8 Start date of employment End date of employment Were/are you? Employed Employed Employed Employed Self-employed Self-employed Self-employed Self-employed Unemployed Unemployed Unemployed Unemployed Full Time Education Full Time Education Full Time Education Full Time Education Name of firm Was the firm FCA Authorised or a member of a network? DO YOU CONSENT TO APPROACHING THIS EMPLOYER? Yes No Yes No Yes No Yes No If yes state network/fca No. Nature of business Address Postcode Is/Was the firm regulated by a body? If yes state name of body Reason for leaving Telephone: Website: 08

9 PROFESSIONAL/CHARACTER REFERENCES Please provide a name & address of one professional referee. This should be an individual who has known you within a professional capacity for at least the last 5 years. Specifically they should have experience of your conduct of business through business dealings with you in a professional capacity (eg. accountant, solicitor, colleague within the same industry who has had professional dealings with you). Please note that this individual should be able to verify your employment history and supply details should there be a gap of more than 3 months in your employment. Title Surname Forename(s) Name of Business Occupation/Qualification Business Address Telephone No address ADDITIONAL INFORMATION 09

10 ADDITIONAL INFORMATION CONTINUED Telephone: Website: 10 MORTGAGES INSURANCE COMMERCIAL BRIDGING EQUITY RELEASE LOANS Authorised and Regulated by the Financial Conduct Authority This is intended for use by Financial Intermediaries only and not the General Public. Ingard is a trading style of Ingard Financial Ltd. Registered in England & Wales. Registered No Registered Office: 1 Nelson Street, Southend on Sea, Essex SS1 1EG.

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