Individual Prospect Checklist Prior to an individual being authorised through our network, it is necessary to establish whether they can be considered as fit and proper, as defined by the Financial Conduct Authority (FCA), and/or whether the individual constitutes any form of business risk to Personal Touch. To assist us in assessing this, please see below a checklist detailing information that will be required as part of your individual application. Please provide the following information when submitting your application to minimise any delays in processing. Registered Individual Application (required for all directors, partners, designated members and advisers) Copy proof of a valid government issued photo identification (i.e. driving licence or passport) Individual credit report. This can be requested through either Experian (www.experian.co.uk, 0844 481 0800), (Equifax (www.equifax.co.uk, 0844 335 0550) or (ddle www.noddle.co.uk) A copy of your last residential mortgage statement (only required for firm principals, director s, partner s & designated member s if this information does not appear on your credit report) Copies of all relevant Financial Services qualification certificates (please note that we require copies of your actual qualification certificates) 1
Individual Application Form To be fully completed by all Director s, Partner s, Designated Member s (including those who are non-selling) and Advisers. 2
1. Main Details Title: Forename: Middle name(s): Surname: Previous names: Company that you are joining: Telephone number: Mobile number: Fax number: Nationality: FCA Individual Reference number (IRN): National Insurance number: Passport number: Date of birth: Website: Email address to be used during application process: Email address to be used once authorised: Residential status: Residential address history covering the last six years (please use a continuation sheet for further addresses); Address 1: Homeowner: Tenant: Living with parents: Other (please specify): Full Address: Dates resident at this address (month/year): From; To: Address 2: Homeowner: Tenant: Living with parents: Other (please specify): Full Address: Dates resident at this address (month/year): From: To: Address 3: Homeowner: Tenant: Living with parents: Other (please specify): Full Address: Position Dates resident being applied at this address for: (month/year): From: To: 3
Are you applying to be a firm supervisor? : : Please specify the role being applied for under Personal Touch: Director (advising): Director (non-advising): Partner (advising): Partner (non-advising): Principal (advising): Principal (non-advising): Manager (advising): Adviser: Permissions: GI only adviser: Please specify the product areas that you wish to be authorised for through Personal Touch: Personal Insurances: Protection products: Private Medical Insurance: Mortgage products: Investments & Pensions: Equity Release: 2. Industry Qualifications Please specify any industry qualifications you hold: CF1 CF2 CF3 CF4 CF5 CF6 CF7 CF8 HR1 ER1 CeLTM CeRER MAQ Bridge CeMap1 CeMap2 CeMap3 FPC1 FPC2 FPC3 AFPC G60 CF9 AF3 CeFA1 CeFa2 CeFA3 Diploma (IFS) Diploma (CII) Other RO1 RO2 RO3 RO4 RO6 RO7 RO8 JO1 JO2 JO3 JO4 JO5 JO6 JO7 JO8 JO9 JO10 JO11 If other, please confirm qualification: 3. Employment Status Please confirm what your employment status will be once authorised through Personal Touch; Employed: Self-employed: If self-employed please confirm the following; Data Protection licence reference number: Consumer Credit interim permission reference number: 4
4. Trading Details Do you have any business interests other than those being applied for through Personal Touch? If yes please provide further details below: Do you receive client introductions from any other businesses or individuals? If yes please provide further details below: Do you introduce clients to any other businesses or individuals? If yes please provide further details below: Do you intend to offer any form of client incentives once authorised through Personal Touch? If yes please provide further details below: Are you recorded as a Director or Designated Member of any other companies? If yes please confirm the names of these companies in the boxes below to include your role, responsibilities and future intentions (please use a continuation sheet for additional Directorship s): Directorship 1: Directorship 2: Directorship 3: Please include a list of any past directorships that you have ever held to include the full business name, reason for leaving and confirmation if you hold any personal liabilities in relation to this business (please use a continuation sheet for further Directorship s): 5
5. Fitness & Propriety Criminal Proceedings When answering the questions in this section you should include matters whether in the UK or overseas. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, if the candidate is subject to the law of England and Wales, you must disclose spent convictions and cautions (other than a protected conviction or caution). (In the following questions, you should include all matters even when the arrest, charge, prosecution or investigation did not result in a conviction, and, in respect of question 4, even where the candidate was not the subject of the investigation.) 1. Have you ever been convicted of any criminal offence (whether spent or not and whether or not in the United Kingdom): a) involving fraud, theft, false accounting, offences against the administration of public justice (such as perjury, Perverting the course of justice and intimidation of witnesses or jurors), serious tax offences or other dishonesty Or b) Relating to companies, building societies, industrial and provident societies, credit unions, friendly societies, insurance, banking or other financial services, insolvency, consumer credit or consumer protection, money laundering, market manipulations or insider dealing? 2. Are you, or have you ever been, the subject of any criminal proceedings, whether in the UK or elsewhere? 3. Have you ever been given a caution in relation to any criminal offence? 4. Have you any convictions for any offences other than those in Question 1 above (excluding traffic offences that did not result in a ban from driving or did not involve driving without insurance)? 5. Have you ever been arrested or charged with any criminal offence or been the subject of any criminal investigation? (You should include all matters even if the arrest, charge or investigation did not result in a conviction.) 6. Have you ever been ordered to produce documents pursuant to any criminal investigation or been the subject of a search (with or without a warrant) pursuant to any criminal investigation? 7. Has any firm at which you hold or have held a position of influence ever: a) Been convicted of any criminal offence? 6
Fitness & Propriety (continued) b) Been summonsed, charged with or otherwise investigated or prosecuted for any criminal offence? c) Been the subject of any criminal proceeding which has not resulted in a conviction? d) Been ordered to produce documents in relation to any criminal investigation or been the subject of a search (with or without a warrant) in relation to any criminal investigation? Civil Proceedings 8. Have you ever been the subject of a judgement debt or award whether satisfied or not? (Including the sum, dates and total number of all judgment debts, awards or CCJ s in the continuation sheet) 9. Have you ever been party to any civil proceedings which resulted in any order against you (other than a judgement debt or award referred to in the question above)? (You should include, for example, injunctions and employment tribunal proceedings.) 10. Are you aware of: a) Any proceedings that have begun or anyone s intention to begin proceedings against you for a CCJ or another judgement debt? b) More than one set of proceedings, or anyone s intention to begin more than one set of proceedings, that may lead to a CCJ or other judgment debt? c) Anybody s intention to claim more than 1,000 of CCJ s or judgment debts in total from the candidate? 11. Do you have any current judgment debts (including CCJs) made under a court order still outstanding, whether in full or in part? 12. Have you ever failed to satisfy any such judgment debts (including CCJs) made under a court order still outstanding, whether in full or part, within one year of the order being made? 13. Have you ever: 7 a) Filed for your own bankruptcy or had a bankruptcy petition served?
Fitness & Propriety (continued) b) Been adjudged bankrupt? c) Been the subject of a bankruptcy restrictions order (including an interim bankruptcy restrictions order) or offered a bankruptcy restrictions undertaking? d) Made any arrangements with creditors, for example a deed of arrangement or an individual voluntary arrangement (or in Scotland a trust deed)? e) Had assets sequestrated? f) Been involved in any proceedings relating to the above matters even if such proceedings did not result in the making of any kind of order against you or result in any kind of agreement? 14. Do you, or any undertaking under your management, have any outstanding financial obligations arising from regulated activities, which have been carried out in the past (whether or not in the UK or overseas)? 15. Has the candidate ever been adjudged by a court or tribunal (whether criminal, civil or administrative) for any fraud, misfeasance, negligence, wrongful trading or other misconduct? 16. Are you currently: a) Party to any civil proceedings? (including those covered in question 14 above) b) Aware of anybody s intention to begin civil proceedings against the candidate? (You should include any ongoing disputes whether or not such dispute is likely to result in any order against the candidate.) 17. Has any firm at which you hold or have held a position of influence ever been: a) Adjudged by a court civilly liable for any fraud, misfeasance, wrongful trading or other misconduct? 8
Fitness & Propriety (continued) b) The subject of a judgement debt or award against the firm? (You should include all CCJs made against the firm, whether satisfied or not.) c) Party to any other civil proceedings which resulted in an order against the firm other than in relation to matters covered in 17a and 17b above? 18. Is any firm at which you currently hold or have held, within the last 12 months from the date of the submission of this form, a position of influence currently: a) A party to civil proceedings? b) Aware of anyone s intention to begin civil proceedings against them? 19. Has any company, partnership or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, in the United Kingdom or elsewhere, at any time during their involvement, or within one year of such an involvement, been put into liquidation, wound up, ceased trading, had a receiver or administrator appointed or entered into any voluntary arrangement with its creditors? Business and Employment Matters 20. Have you ever been: a) Disqualified from acting as a director or similar position (one where you acted in a management capacity or conducted the affairs of any company, partnership or unincorporated association)? b) The subject of any proceedings of a disciplinary nature (whether or not the proceedings resulted in any finding against you)? c) The subject of any investigation which has led or might lead to disciplinary proceedings? d) tified of any potential proceedings of a disciplinary nature against you? 9 e) The subject of an investigation into allegations of misconduct or malpractice in connection with any business activity? (This question covers internal investigation by an authorised firm, as well as investigation by a regulatory body, at any time.)
Fitness & Propriety (continued) 21. Have you ever been refused entry to, or been dismissed, suspended or requested to resign from, any professional, vocation, office or employment, or from any fiduciary office or position of trust whether or not remunerated? 22. Do you have any material written complaints made against you by your clients or former clients in the last five years which the candidate has accepted, or which are awaiting determination, or have been upheld by an ombudsman or complaints scheme? Regulatory Matters 23. In relation to activities regulated by the FCA and/or PRA or any other regulatory body have: You, or Any company, partnership or unincorporated associate of which you are or have been a controller, director, senior manager, partner or company secretary, during your association with the entity and for a period of three years after you ceased to be associated with it, ever a) Been refused, had revoked, restricted, been suspended from or terminated, any licence, authorisations, registration, notification, membership or any other permission granted by any such body? b) Been criticised, censured, disciplined, suspended, expelled, fined or been the subject of any other disciplinary or interventional action by any such body? c) Received a warning (whether public or private) that such disciplinary or interventional action may be taken against you or the firm? d) Been the subject of an investigation by any regulatory body, whether or not such an investigation resulted in a finding against you or the firm? e) Been required or requested to produce documents or any other information to any regulatory body in connection with such an investigation (whether against the firm or otherwise)? f) Been investigated or been involved in an investigation by an inspector appointed under companies or any other legislation, or required to produce documents to the Secretary of State, or any other authority, under any such legislation? 10
Fitness & Propriety (continued) g) Ceased operating or resigned whilst under investigation by any such body or been required to cease operating or resign by any regulatory body? h) Decided, after making an application for any licence, authorisation, registration, notification, membership or any permission granted by any such body, not to proceed with it? i) Been the subject of any civil action related to any regulated activity which has resulted in a finding by a court? j) Provided payment services or distributed or redeemed e-money on behalf of a regulated firm or itself under any contractual agreement where that agreement was terminated by the regulated firm? k) Been convicted of any criminal offence, censured, disciplined or publicly criticised by any inquiry, by the Takeover Panel or any governmental or statutory authority or any other regulatory body (other than as indicated in this group of questions). 24. In relation to activities regulated by the FCA/PRA or any other regulatory body, have you or any firm at which you hold or have held a position of influence at any time during and within one year of your association with the firm ever: a) Been found to have carried on activities for which authorisation or registration by the FCA/PRA or any other regulatory body is required without the requisite authorisations? b) Been investigated for the possible carrying on of activities requiring authorisation or registration by the FCA/PRA or any other regulatory body without the requisite authorisation whether or not such investigation resulted in a finding against you? c) Been found to have performed a controlled function (or an equivalent function requiring approval by the FCA/PRA or any other regulatory body) without the requisite approval? d) Been investigated for the possible performance of a controlled function (or an equivalent function requiring approval by the FCA/PRA or any other regulatory body) without the requisite approval, whether or not such investigation resulted in a finding against you? 11
Fitness & Propriety (continued) e) Been found to have failed to comply with an obligation under the Electronic Money Regulations 2011 or Payment Services Regulations 2009 to notify the FCA/PRA of the identity of a person acting in a position of influence over its electronic money or payment services business? f) Been the subject of disqualification direction under section 59 of the Financial Services Act 1986 or a prohibition order under section 56 FSMA, or received a warning notice proposing that such a direction or order be made, or received a private warning? Other Matters 25. Are you, in the role to which the application relates, aware of any business interests, employment obligations, or any other circumstance which may conflict with the performance of which approval is now being sought? 26. Are you aware of any other information relevant to this notification that we might reasonably expect from you? If you have answered YES to any of the questions you must provide full details below or on the continuation sheet attached (even if you have given the information before), clearly indicating the question or questions to which the details relate. If there is any other information that you feel may be relevant to this application that may impact on your fitness and propriety that has not been asked on this application form, it must be detailed below. n-disclosure of any adverse information will result in your application being declined. 12
6. Employment & Education History Please provide your employment and education history covering the last ten full years. If a company is regulated by a network please state the network. If there is any gap in employment please provide full details of unemployment confirming if any benefits were claimed. We also require details of full time education or time travelling. (If required, please continue on a continuation sheet). Failure to supply all employment/education information will delay your application. Employer/Education institution 1: Dates of employment (mnth/yr) From: To: Company name: Company address: Job Title and responsibilities: Company email address: Company FCA number: Company phone number: Reason for leaving: Permission to reference employer: Did you achieve Competent Adviser status: Is this company still trading: Is this company Directly Authorised by the FCA: Is this company authorised by a network: Name of network: Permission to reference network: Employer/Education institution 2: Dates of employment (mnth/yr) From: To: Company name: Company address: Job Title and responsibilities: Company email address: Company FCA number: Company phone number: Reason for leaving: Permission to reference employer: Did you achieve Competent Adviser status: Is this company still trading: Is this company Directly Authorised by the FCA: Is this company authorised by a network: Name of network: 13 Permission to reference network:
Employment & Education History (cont) Employer/Education institution 3: Dates of employment (mnth/yr) From: To: Company name: Company address: Job Title and responsibilities: Company email address: Company FCA number: Company phone number: Reason for leaving: Permission to reference employer: Did you achieve Competent Adviser status: Is this company still trading: Is this company Directly Authorised by the FCA: Is this company authorised by a network: Name of network: Permission to reference network: Employer/Education institution 4: Dates of employment (mnth/yr) From: To: Company name: Company address: Job Title and responsibilities: Company email address: Company FCA number: Company phone number: Reason for leaving: Permission to reference employer: Did you achieve Competent Adviser status: Is this company still trading: Is this company Directly Authorised by the FCA: Is this company authorised by a network: Name of network: Permission to reference network: 14
Employment & Education History (cont) Employer/Education institution 5: Dates of employment (mnth/yr) From: To: Company name: Company address: Job Title and responsibilities: Company email address: Company FCA number: Company phone number: Reason for leaving: Permission to reference employer: Did you achieve Competent Adviser status: Is this company still trading: Is this company Directly Authorised by the FCA: Is this company authorised by a network: Name of network: Permission to reference network: Employer/Education institution 6: Dates of employment (mnth/yr) From: To: Company name: Company address: Job Title and responsibilities: Company email address: Company FCA number: Company phone number: Reason for leaving: Permission to reference employer: Did you achieve Competent Adviser status: Is this company still trading: Is this company Directly Authorised by the FCA: Is this company authorised by a network: Name of network: Permission to reference network: Please list any financial services networks that you have been registered through within the last ten years that have not been listed above: 15
7. Assets and Liabilities Assets; Residential Property: Investment Property 1: Investment property 2: Investment property 3: Investment property 4: Full Address; Full Address; Full Address; Full Address; Full Address; Full Address; Full Address; Full Address; Motor Vehicles: Investments/savings (Please specify): Other (please specify): Cash in bank: Total Assets; Liabilities: Residential mortgage: Investment mortgage 1: Investment mortgage 2: Investment mortgage 3: Investment mortgage 4: (Please use a continuation sheet for further Investment mortgages) Secured loans, HP n secured loans: Credit cards/store cards: Taxation liabilities: Industry debt: Potential indemnity liability: Overdraft: Other (please specify): Total Liabilities: Total solvency (Assets liabilities): 16
8. Professional Reference Please supply the name and address of a professional reference. A professional reference can be any one of the following; bank/ building society official, barrister, accountant, justice of the peace, local government officer, minister of a recognised religion, police officer, solicitor, surveyor, teacher or lecturer. Family members or individual s you have employed should not be used. Title: Forename: Surname: Occupation: How long have you known this person? What relationship do you have with this person? In what capacity has this person acted on your behalf? Address: Postcode: 9. Declaration I hereby authorise Personal Touch Financial Services Ltd (registered company number (3406454) to seek and disclose information from/to associated third parties as appropriate both now and in the future. I confirm that the information provided in this application form is to the best of my knowledge and belief, complete and accurate. I understand that the supply of any misleading information or any attempt to mislead Personal Touch Financial Services Ltd will be an act of misconduct and could lead to termination. I will notify Personal Touch Financial Services Ltd of any material change within this application whilst it is under consideration. Please note that authorisation is not guaranteed and Personal Touch Financial Services Ltd will not reimburse any costs that are incurred during the application process. Title: Forename: Surname: Signature: Date: Please return this application to: Financial and Propriety, Personal Touch Financial Services Ltd, Trinity 3, Trinity Park, Solihull, West Midlands, B37 7ES Phone 0121 767 1063 Fax 0121 767 1085 Email financialandpropriety@personaltouchfs.com 17
10. Continuation Sheet 18