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Short Form A - UK and overseas firms (not EEA)

By Bernard Hicks,2014-04-19 16:53
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Short Form A - UK and overseas firms (not EEA)

    Application number (for FSA use only)

    The FSA has produced notes which will assist both the applicant and the candidate in answering the questions in this form. Please read these notes, which are available on the FSA’s website at

    http://www.fsa.gov.uk/pubs/forms/imap_forma_notes.doc. Both

    the applicant and the candidate will be treated by the FSA as having taken these notes into consideration when completing their answers to the questions in this form.

    Short Form A UK and Overseas firms (not

    Incoming EEA)

    Application to perform

    controlled functions

    under the approved persons

    regime

    FSA Handbook Reference: SUP 10 Annex 4D

    Name of candidate (to be completed by applicant firm)

    Name of firm (as entered in 2.01)

    Firm reference number (as entered in 2.02)

    The Financial Services Authority

    Permissions, Decisions & Reporting Division

    25 The North Colonnade

    Canary Wharf

    London E14 5HS

    United Kingdom

    Telephone +44 (0) 845 606 9966

    Facsimile +44 (0) 207 066 0017

    E-mail iva@fsa.gov.uk

    Website http://www.fsa.gov.uk

    Registered as a Limited Company in England and Wales No 1920623. Registered Office as above

    1.01 a Candidate FSA Individual Reference Number (IRN)

     The above question(s) should be completed whether submission of this form is online or in one of the other ways set out in SUP 15.7

    Version 7

     b OR name of previous regulatory body

     c AND previous reference number (if applicable)

    1.02 Title (e.g. Mr, Mrs, Ms, etc)

    1.03 Surname

    1.04 ALL forenames

    1.05 Name commonly known by

    1.06 Date of birth / /

    (dd/mm/yyyy)

    1.07 National Insurance number

    1.08 Previous name

    1.09 Date of name change / / 1.10 a Nationality

     b Passport number

    (if National Insurance number not

    available)

    1.11 Place of birth

    I have supplied further information YES NO ; related to this page in Section 6 Short Form A UK and Overseas 2 Application to perform controlled functions under the approved persons regime Page 2

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1.12 a Private address

     b Postcode

    Dates resident at this address c From / To PRESENT (mm/yyyy)

    (If address has changed in the last three years, please provide addresses for the previous three years.)

1.13 a Previous address 1

     b Postcode

    Dates resident at this address c From / To / (mm/yyyy)

1.14 a Previous address 2

     b Postcode

    Dates resident at this address c From / To / (mm/yyyy)

    I have supplied further information YES NO ; related to this page in Section 6

    2.01 Name of firm making the application Short Form A UK and Overseas 3 Application to perform controlled functions under the approved persons regime Page 3

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2.02 FSA Firm Reference Number (FRN)

    2.03 a Who should the FSA contact at the firm in relation

    to this application?

     b Position

     c Telephone

     d Fax

     e E-mail

    I have supplied further information YES NO ; related to this page in Section 6

    3.01 Nature of the arrangement a Employee between the candidate and

    the applicant. b Group employee

     Name of group

     c Contract for services

     d Partner/Sole trader

     e Appointed representative/tied agent customer function Short Form A UK and Overseas 4 Application to perform controlled functions under the approved persons regime Page 4

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     AR firm name and reference number

     f Appointed representative/tied agent governing function

     AR firm name and reference number

     g Other

     Give details

    3.02 For applications from a single firm, please tick the boxes that correspond to the controlled functions to be

    performed.

    If the controlled functions are to be performed for more than one firm, please go to question 3.05

     a Significant CF 1 Director function influence CF 2 Non-executive director function functions

    CF 3 Chief executive function

    CF 4 Partner function

    CF 5 Director of an unincorporated association function

    CF 6 Small friendly society function

     Significant CF 8 Apportionment and oversight function influence

    (this function is not applicable to all firms please refer to Notes for Completing Form A) functions

    continued CF 10 Compliance oversight function

    CF 11 Money laundering reporting function

    CF 12 Actuarial function

    CF 12A With-profits actuary function

    CF 12B Lloyd's Actuary function

    CF 28 System and controls function

    CF 29 Significant management function

     b Customer

    function CF 30 Customer function

3.03 Effective date of controlled functions / /

    indicated above

    3.04 Job title (mandatory for controlled functions 28 & 29)

    Please refer to notes on the requirements

    for submitting a C.V.

     Insurance mediation

    Will the candidate be responsible for YES NO Insurance mediation at the firm?

    (Note: Yes can only be selected if the

    individual is applying for (CF1, 3-8 or 29)

Short Form A UK and Overseas 5 Application to perform controlled functions under the approved persons regime Page 5

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I have supplied further information YES NO ; related to this page in Section 6

Short Form A UK and Overseas 6 Application to perform controlled functions under the approved persons regime Page 6

Version 7

    3.05 Complete this section only if the application is on behalf of more than one firm.

    List all firms within the group (including the firm entered in 2.01) for which the candidate requires approval and

    the requested controlled function for that firm.

     FSA Firm Job title Reference Controlled (mandatory for controlled function 28 & 29) Effective date Number Name of firm function

     a

     / /

     b

     / /

     c

     / /

     d

     / /

     e

     / /

    I have supplied further information YES NO ; related to this page in Section 6

    Short Form A UK and Overseas 7 Application to perform controlled functions under the approved persons regime Page 7

    Version 7

    This section has been removed. However if there has been a change to the detail in this section since your last approval, you must submit a Long form A as opposed to a Short Form A informing the FSA of the revised detail.

    This section has been removed. However if there has been a change to the detail in this section since your last approval, you must submit a Long form A as opposed to a Short Form A informing the FSA of the revised detail.

Short Form A UK and Overseas 8 Application to perform controlled functions under the approved persons regime Page 8

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Section 6

    6.00 ; If there is any other information the candidate or the firm considers to be relevant to the

    application, it must be included here.

    ; If this application relates to a Significant influence controlled function then please provide

    full details of

    o why the candidate is competent and capable to carry out the controlled function(s)

    applied for.

    o why the appointment complements the firm's business strategy, activity and market

    in which it operates.

    o how the appointment was agreed including details of any discussions at governing

    body level (where applicable).

    ; Please also include here any additional information indicated in previous sections of the Form.

    ; Please include a list of all directorships currently or previously held by the candidate in the

    past 10 years (where director has the meaning given in the Glossary.)

    ; If there is insufficient space, please continue on a separate sheet of paper, and clearly identify the

    section and question to which the additional information relates.

     Question Information

    Short Form A UK and Overseas 9 Application to perform controlled functions under the approved persons regime Page 9 Version 7

     Declaration of Candidate

     Knowingly or recklessly giving the FSA information which is false or misleading in a material particular may

    be a criminal offence (section 398 of the Financial Services and Markets Act 2000).

    It should not be assumed that information is known to the FSA merely because it is in the public domain or

    has previously been disclosed to the FSA or another regulatory body. If there is any doubt about the

    relevance of information, it should be included.

    For the purposes of complying with the Data Protection Act, the personal information provided in this Form

    will be used by the FSA to discharge its statutory functions under the Financial Services and Markets Act

    2000 and other relevant legislation, and will not be disclosed for any other purpose without the permission of

    the applicant.

    With reference to the above, the FSA may seek to verify the information given in this Form including

    answers pertaining to fitness and propriety. This may include a credit reference check.

    In signing the form below:

    a) I authorise the FSA to make such enquiries and seek such further information as it thinks

    appropriate in the course of verifying the information given in this Form. Individual candidates may

    be required to apply to the Criminal Records Bureau for a search to be made as to whether any

    criminal records are held in relation to them and to disclose the result of that search to us. I also

    understand that the results of these checks may be disclosed to the firm submitting this application.

    b) I confirm that the information in this Form is accurate and complete to the best of my knowledge

    and belief and that I have read the notes to this Form.

    c) I confirm that I understand the regulatory responsibilities of my proposed role as set out in the

    Statements of Principle and Code of Practice for Approved Persons

     ( http://fsahandbook.info/FSA/html/handbook/APER)

    7.01 Candidate's full name

    *7.02 Signature

     / / Date

* The above question(s) should only be completed if the form is being submitted in one of the ways set out in SUP 15.7 other than

    online submission. It should not be completed if submission of this form is online. The above question(s) should be completed whether submission of this form is online or in one of the other ways set out in SUP

    15.7

    Short Form A UK and Overseas 10 Application to perform controlled functions under the approved persons regime Page 10 Version 7

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