FORM 28 APPLICATION FOR TEMPORARY LICENCE te for applicant: Please affix your photograph here. PART A (to be filled by the applicant) SECTION I: PROFILE Personal Details Title: Name: (as shown in passport) Other name: Date of birth: (dd/mm/yyyy) Place of birth: (town/city, country) Present country(s) of citizenship: Gender: Male Female Status: Foreigner Malaysian Address and Contact Details In Your Home Country Home Address: Contact no.: Home: Handphone: Office: Fax: IC Details (for Malaysian only) New IC no.: Old IC no.: Passport Details Passport no.: Expiry date: (dd/mm/yyyy) Country of issue: 1
Marital Status Details Single Engaged Married (please provide spouse s details) Divorced Separated Widowed Spouse details: (if applicable) Name: NRIC no.: (for Malaysian) Passport details: (for non-malaysian) Passport no.: Expiry date: (dd/mm/yyyy) Country of issue: Details of Employer: (if in employment) Name: Address: Contact details: Office: Fax: SECTION II: COMPETENCE 1) Please provide information on your highest academic or professional qualification Qualification Name of Institution Year Awarded 2) Please provide information on your employment history for the past 10 years Date (mm/yyy) Name of employer & designation held Description of duties 2
SECTION III: CHARACTER 1) Has the applicant: a. Been convicted of any offence, or are there any proceedings now pending which may lead to a conviction of any offence involving fraud or other dishonesty or violence? b. Had judgment involving findings of fraud or other dishonesty, violence, misrepresentation, breach of contract, breach of fiduciary duty or professional negligence given against him, as the case may be, in any civil proceedings, or are there any proceedings now pending that may lead to such a judgment? c. Contravened any written law designed for protecting members of the public against financial loss due to dishonesty, incompetence or malpractice by persons concerned in the provision of financial services or the management of companies or against financial loss due to the conduct of discharged or undischarged bankrupts? d. Been declared a bankrupt or entered into a composition or arrangement with creditors? e. Been subject to any form of disciplinary proceedings or actions by any professional or regulatory body? 2) Has the applicant, been involved in the management of a corporation in Malaysia or elsewhere which at the time of his involvement in the corporation: a. Been convicted of any offence, or are there any proceedings now pending which may lead to a conviction of any offence, involving fraud or other dishonesty? 3
b. Had judgment involving findings of fraud or other dishonesty, or violence, misrepresentation, breach of contract, breach of fiduciary duty or professional negligence given against it in any civil proceedings, or are there any proceedings now pending that may lead to such a judgment? c. Contravened any written law designed for protecting members of the public against financial loss due to dishonesty, incompetence or malpractice by persons concerned in the provision of financial services or the management of companies, or against financial loss due to the conduct of discharged or undischarged bankrupts? d. Had a receiver and/or manager been appointed in respect of any of the assets of the said corporation? e. Entered into a compromise or arrangement with creditors or members? f. Had a petition presented in a court for its winding up? g. Been subjected to any form of disciplinary proceedings or action by any professional or regulatory body? SECTION IV: PROPOSED REGULATED ACTIVITY 1) Please tick ( ) the regulated activities (within the meaning of Schedule 2 of the Capital Markets and Services Act 2007 (CMSA)) that you intend to provide in Malaysia. Dealing in securities Trading in futures contracts Fund management Advising on corporate finance* Investment advice* Financial planning *If you are employed with a foreign intermediary with no presence in Malaysia, the regulated activities that you may apply for is limited to advising on corporate finance or investment advice. 4
2) Please provide details of your proposed activities, clients and description of duties in Malaysia 3) What is the value proposition of the activities and how does it contributes to the overall development of the capital market in Malaysia 4) Will the product(s) offered through your service require Securities Commission ( SC ) approval under Section 212 of the CMSA? Yes (please provide details) SECTION V: STATUS ON YOUR HOME REGULATORY REGIME 1) (a) Please provide information on the applicant s employer(s) status. Please enclose a copy of all current licenses, registrations or approval documents. If the licence, registration or approval document is not in English, the applicant shall enclose an accurate translation thereof in the English language. Employer Name of regulatory authority Status (Licensed, registered, approved etc) Licence, registration or approval number Description of activity regulated Conditions or restrictions attached to the licence, registration or approval, if any Period (mm/yy) From To (b) Please provide information on the applicant s status. Please enclose a copy of all current licenses, registrations or approval documents. If the licence, registration or approval document is not in English, the applicant shall enclose an accurate translation thereof in the English language. Name of regulatory authority Status (Licensed, registered, approved etc) Licence, registration or approval number Description of activity regulated Conditions or restrictions attached to the licence, registration or approval, if any Period (mm/yy) From To 5
SECTION VI: ADDITIONAL INFORMATION 1) Please give us any other information that you think will be relevant to us in considering your application. SECTION VII: SUPPORTING DOCUMENT - Please provide annexures for the following information. Description 1. A recent passport sized photograph (45mmx35mm) of the applicant 2. Certified copy of applicant s valid passport 3. Certified copy of applicant s New I/C (for Malaysian only) 4. Reference letter(s) 5. Details of any of the applicant s related, subsidiary and associate companies which are or were involved in any regulated activities in Malaysia or elsewhere and their licence/registration status 6. Certified copy of proof for all licenses, registration or approval, that entitle you to provide financial services mentioned earlier in item 1 Section VI. Copies should be certified as true copies by persons who are authorised in your home jurisdiction, e.g. Commissioner for oaths or tary Public or Regulator or Solicitors or Authorised person in the company 7. Other relevant documents Submission Yes N/A Appendix If any document is not in English, a certified translation of that document into English is required. SECTION VIII: APPLICANT S DECLARATION I declare that all information provided in this application (including all supplements and attachments) is true and correct. I undertake to notify the Securities Commission and my monitoring officer immediately of any changes to the circumstances listed above at any time after my application has been approved to enable the SC to reassess my status as a Temporary Licence holder. Signature Applicant s name: Date (dd/mm/yyyy): 6
PART B (to be filled by the applicant s monitoring officer) SECTION I: DETAILS OF SPONSOR IN MALAYSIA Sponsor name: Type of business: Registered address: Correspondence address: Contact information: E-mail address: Telephone: Fax: SECTION II: DETAILS OF MONITORING OFFICER IN MALAYSIA Title: Name: (as shown in NRIC/passport) Other name: Date of birth: (dd/mm/yyyy) Place of birth: (town/city, country) Present country(s) of citizenship: Gender: Male Female Designation: Contact no.: Home: Handphone: E-mail address: Status: Office: Foreigner Fax: Malaysian Passport Details Passport no.: Expiry date: (dd mm yyyy) IC Details Old IC no.: New IC no.: Country of issue: 7
SECTION III: SUPPORTING DOCUMENT - Please provide annexures for the following information. Description Submission Yes N/A Appendix 1. Certified copy of monitoring officer s New I/C or passport 2. Proof of monitoring officer s employment with current company 3. Other relevant documents If any document is not in English, a certified translation of that document into English is required. SECTION III: MONITORING OFFICER S DECLARATION I declare that I have reviewed all information provided in this application (including all supplements and attachments) and that it is true and correct. I understand that I have to complete and submit the Monitoring Officer s Report for the Temporary Licence Holder Form to the Securities Commission half-yearly, starting six (6) months after the issuance of the Temporary Licence. Signature Monitoring officer s name: Date (dd/mm/yyyy): 8