Annex Communication _2009_20-3 of 08 May 2009 A form to be filled in by every applicant for reappointment to one of the positions mentioned above. Scope: Credit institutions, investment firms, insurance companies, management companies of undertakings for collective investment, public investment companies, settlement institutions or equivalent institutions, financial holding companies, insurance holding companies and mixed financial holding companies. Preface: The personal information submitted on this form will be processed by the Banking, Finance and Insurance Commission (), rue du Congrès/Congresstraat 12-14, 1000 Brussels, in accordance with the Law of 8 December 1992 on the protection of privacy with regard to the processing of personal data. The will process these data with a view to verifying compliance with the legal provisions listed below. The processed data may be passed on to third parties, where appropriate, only under the conditions set out in Articles 74 and 75 of the Law of 2 August 2002 on the supervision of the financial sector and on financial services. Within the boundaries provided for in the regulations concerning the protection of privacy, the natural persons whose personal data have been processed have the right to inspect and correct such data in accordance with Articles 10 and 12 of the aforementioned Law of 8 December 1992. Scope The information requested on this form will be used in the context of supervision of compliance with the provisions of, as applicable: - Articles 18 and 26bis of the Law of 22 March 1993 on the legal status and supervision of credit institutions 1, - Articles 60 and 69bis of the Law of 6 April 1995 on the legal status and supervision of credit institutions, - Article 90, 1, of the Law of 9 July 1975 on the supervision of insurance companies, - Article 91ter, 1, second paragraph of the same law, - Articles 38, 151 and 161bis of the Law of 20 July 2004 on certain forms of collective management of investment portfolios, - Article 9, first paragraph, of the Royal Decree of 26 September 2005 on the legal status of settlement institutions and assimilated institutions, - Article 4, 4, of the Royal Decree of 12 August 1994 on the supervision of credit institutions on a consolidated basis, 1 The legal provisions referred to in this form can be found on the web site of the : http://www.cbfa.be.
_2009_20-3 dd. 08/05/2009 2 / 6 - Article 15, 1, of the Royal Decree of 21 November 2005 on the supplementary group supervision of credit institutions, insurance companies, investment firms and management companies of undertakings for collective investment belonging to a financial services group, and amending the Royal Decree of 22 February 1991 containing general regulations relating to the supervision of insurance companies and the Royal Decree of 12 August 1994 on the supervision of credit institutions on a consolidated basis. - or Article 79, 1, 5, and Article 80, 1, 2, of the Law of 22 March 1993 and Article 20, 1, 6, of the Royal Decree of 20 December 1995 on foreign investment firms, pursuant to which the same legal provisions also apply to managers of branches established in Belgium by credit institutions or investment firms governed by the law of States that do not belong to the European Economic Area (EEA). Branches established in Belgium by insurance companies governed by the law of States that do not belong to the European Economic Area must in principle comply with all provisions applicable to companies governed by Belgian law, including the aforementioned Article 90, 1, of the Law of 9 July 1975. Pursuant to these provisions, the must, in the event of a renewal of an appointment with: - credit institutions, - investment firms, - insurance companies, - management companies of undertakings for collective investment, - public investment firms, - settlement institutions, - institutions equivalent to settlement institutions, - financial holding companies, - insurance holding companies, - mixed financial holding companies (hereafter "the institutions"), give an opinion on the necessary professional integrity, expertise and appropriate experience on the part of the applicant in question. Structure of the form Where the persons in question are first nominated, they must fill out the appropriate form relating either to the position of non-executive director or to the position of senior manager. In the event of a reappointment, only the present form needs to be filled out. Where certain information provided on this form so requires, or where the person concerned wishes to do so, he/she will be given the opportunity to provide the orally with any additional information that he/she may deem useful. In addition, the draws attention to the fact that Article 108 of the Law of 22 March 1993, Article 152 of the Law of 6 April 1995, Article 210 of the Law of 20 July 2004 and Article 88 of the Law of 9 July 1975 authorize it to obtain information from the judicial authorities concerning any conviction for or investigation into an infringement of the Law of 22 March 1993, the Law of 6 April 1995, the Law of 9 July 1975, the Law of 20 July 2004 or of one of the legal provisions referred to in Article 19 of the Law of 22 March 1993, Article 61 of the Law of 6 April 1995 or Articles 39 and 152 of the Law of 20 July 2004. The form must be duly completed, dated and signed by the applicant non-executive director/senior manager. In the case of senior managers, the form must be countersigned by the chairman of the management committee of the institution concerned, where such a committee has been set up within the institution, or
_2009_20-3 dd. 08/05/2009 3 / 6 by the chairman of the board of directors of the institution if the institution has no management committee or if the proposed reappointment concerns the chairman of the management committee. With regard to senior managers of Belgian branches of institutions governed by the law of States that do not belong to the European Economic Area, the form must be countersigned by the senior manager of the foreign institution to which they are answerable. For non-executive directors, the document must be countersigned by the chairman of the statutory governing body. For the chairman of the statutory governing body, the document must be countersigned by two other nonexecutive members of the governing body. * * *
_2009_20-3 dd. 08/05/2009 4 / 6 1. Name of the institution for which the application is being submitted 2. Identity of the applicant Surname Given name(s) Place and date of birth Nationality Domicile Place of residence (if different from domicile) Telephone/mobile phone number (professional, if possible) Email address (professional, if possible) Original expiry date of the appointment Expiry date of the reappointment
_2009_20-3 dd. 08/05/2009 5 / 6 3. Declaration as to the applicant's expertise and appropriate experience Please specify below, where appropriate, whether there is any new information since the completion of the original form that is relevant in assessing the applicant's expertise and appropriate experience. 4. Professional integrity 4. a) Declaration of "no new information" The applicant non-executive director or senior manager declares that there is "no new information" that could have bearing on the assessment of his or her professional integrity. This means, among other things, that he or she would give the same answers (yes or no) as at the time of the original appointment to the questions contained in the forms intended for first-time non-executive directors and senior managers. This also means that there have been no changes with regard to the applicant's criminal record. Declaration: 4. a) Declaration of "new information" The applicant non-executive director or senior manager declares that there is "new information" that could have bearing on the assessment of his or her professional integrity. This means, among other things, that he or she would give different answers (yes or no) from those given at the time of the original appointment to the questions contained in the forms intended for first-time non-executive directors and senior managers. In this case, the applicant is asked to provide an explanation of the new information. New information:
_2009_20-3 dd. 08/05/2009 6 / 6 Declaration of the applicant senior manager or non-executive director "I, the undersigned... (surname and given name(s) of the applicant senior manager or non-executive director), hereby confirm the accuracy of the answers provided to the above questions and undertake to inform the Banking, Finance and Insurance Commission immediately of any change relating to one or more answers to these questions. As regards these questions, I am aware that communicating incorrect information to the Banking, Finance and Insurance Commission may adversely affect its assessment of my application or, subsequently, of the qualifications required of me to exercise the duties of senior manager that will be entrusted to me." Date and signature of the applicant senior manager or non-executive director Declaration by the chairman of the statutory governing body or of the chairman of the management committee of the institution concerned, or of the senior manager of an institution governed by the law of a State that does not belong to the European Economic Area to which the senior manager of the Belgian branch is answerable. "In my capacity 2 3 : o as chairman of the statutory governing body o as chairman of the management committee o as senior manager of the foreign institution to which the senior manager of the Belgian branch is answerable of... (name of the institution concerned), I the undersigned... (surname and given name(s)), hereby declare, after having made the usual verifications, that the information provided by... (surname and given name(s) of the applicant senior manager or non-executive director) to the Banking, Finance and Insurance Commission in this document is, to my knowledge, correct. I undertake to immediately inform the Banking, Finance and Insurance Commission of any and all changes to this information I may become aware of and that would be likely to have an impact on the Banking, Finance and Insurance Commission's assessment of the professional integrity and/or appropriate experience of the applicant senior manager or non-executive director." Date, title and signature 2 3 Delete as appropriate. See the end of the preface above.