CAYMAN ISLANDS MONETARY AUTHORITY

Personal Questionnaire for Directors, Shareholders, Managers and Controllers*

 

THE BANKS AND TRUST COMPANIES LAW, 1989
THE INSURANCE LAW, 1979
THE MUTUAL FUNDS LAW
THE COMPANIES MANAGEMENT LAW, 1984
If insufficient space is provided, please attach a separate sheet of paper.
1.

 

 

Name of institution in connection with which this questionnaire is being completed.  
2.

 

Surname

Forename(s)

Any previous name(s) by which you have been known.

 
3.

 

 

Are you completing this questionnaire as a director, shareholder, manager or a controller. (See Note on page 4)  
4. Private Address


 
5.

 

 

 

 

 

 

Previous private address during the last ten years

(with relevant dates)

 
6.

 

 

Date of Birth

Place of birth (including town, state and country)

 
7.

 

Nationality, and how it was acquired (e.g. birth, naturalisation, marriage)  

*Except when exempted by the Cayman Islands Monetary Authority this form is to be completed by all persons seeking approval to become directors, shareholders, managers or controllers of an institution which is licensed or applying to be licensed under the above laws.

If insufficient space is provided, please attach a separate sheet of paper.


 

8.

 

 

 

 

Present occupation or employment and occupations and employment during the last ten years, including the name of the employer, the nature of the business, the position held and relevant dates.  
9.

 

 

 

 

 

 

Of what bodies corporate -

(a) are you now a director or controller?

(b) have you been a director or controller at any time during the last ten years?

(specify the country of incorporation in each case)

 
10.

 

 

Professional qualifications and year in which they were obtained.  
11. Have you at any time been convicted of any offence (other than (a) an offence committed when you were under the age of 18 years unless the same was committed within the last ten years, or (b) an offence in connection with the use or ownership of a motor vehicle which was tried in a court of summary jurisdiction) by any court, whether civil or military, in any jurisdiction? If so, give full particulars of the court by which you were convicted, the offence and the penalty imposed and the date of conviction.  

If insufficient space is provided, please attach a separate sheet of paper.


 

12.

 

 

Have you, anywhere, been censured, disciplined or criticised by any professional body to which you belong or have belonged, or have you every held a practising certificate subject to conditions? If so, give full particulars.  
13.

 

Have you, or any body corporate, partnership or unincorporated institution with which you are, or have been associated as a director, shareholder, manager or controller, been the subject of an investigation, anywhere, by a governmental, professional or other regulatory body? If so, give full particulars.  
14.

 

 

Have you, anywhere, been dismissed from any office or employment or barred from entry to any profession or occupation? If so, give full particulars.  
15.

 

 

Have you been adjudicated bankrupt by a court in any jurisdiction? If so, give full particulars.  
16.

 

 

Have you failed to satisfy any debt adjudged due and payable by you as a judgement-debtor under an order of a court in any jurisdiction? If so, give full particulars.  
17. Have you, in connection with the formation, control or management of any body corporate, partnership or unincorporated institution been adjudged by a court, in any jurisdiction, civilly liable for any fraud, misfeasance or other misconduct by you towards such a body or company or towards any members thereof? If so, give full particulars.  

 

If insufficient space is provided, please attach a separate sheet of paper.


 

18.

 

Has any body corporate, partnership or unincorporated institution with which you were associated as a director, shareholder, manager or controller, anywhere, been compulsorily wound up or made any compromise or arrangement with its creditors or creased trading in circumstances where its creditors did not receive or have not yet received full settlement of their claims, either while you were associated with it or within one year after you ceased to be associated with it? If so, give full particulars.  
19.

 

 

 

 

In carrying out your duties you will be acting on the directions or instructions of any other person? If so, give full particulars.  

I CERTIFY that the above information is complete and correct to the best of my knowledge and belief and I undertake that, as long as I continue to be a director, shareholder, manager or controller of an institution authorised under the above laws, I will notify the Cayman Islands Monetary Authority of any material changes affecting the completeness of the answers to question 11-18 above within a period of twenty-one days.

 

Date_____________________________________

Signed_________________________________________

 

NOTE

CONTROLLERS

A controller includes:

(a) any person who is entitled to exercise control of 15% or more of the voting power over the institution or over another company of which it is a subsidiary:

(b) any person, whether a shareholder or not, in accordance with whose directions or instructions the directors of the institution, or of another company of which it is a subsidiary, are accustomed to act.

Where a controller is a body corporate the Cayman Islands Monetary Authority will look through that body to the ultimate controller from whom the above information will be sought.