Download credit union south fit and proper declaration

CREDIT UNION SOUTH
FIT AND PROPER DECLARATION
Please complete this declaration by responding to all of the questions, providing the
information requested, and signing and dating this declaration where indicated.
Inquiries Related To The:
• COMPANIES ACT 2006
• CRIMES ACT 1961
• FRIENDLY SOCIETIES AND CREDIT UNIONS ACT 1982
• INSOLVENCY ACT 2006
• INSURANCE (PRUDENTIAL SUPERVISION) ACT 2010
• INVESTMENT ADVISERS (DISCLOSURE) ACT 1996
• RESERVE BANK OF NEW ZEALAND ACT 1989
• RESERVE BANK OF NEW ZEALAND AMENDMENT ACT 2008
• FINANCIAL MARKETS CONDUCT ACT 2013
• NON-BANK DEPOSIT TAKERS ACT 2013 (NBDT Act)
1. Have you at any time ever been found by a civil or criminal court or tribunal
to have been guilty of serious wrongdoing, or having aided, abetted, counselled or
procured another person to engage in serious wrongdoing, including being:
• convicted of any offence involving the management of a corporation
• convicted of an offence under any of the above Acts or similar Act that was
previously in force, or a similar law of a foreign country
• a disqualified person under any of the above Acts, or similar Act that was
previously in force, or a similar law of a foreign company convicted of a crime of dishonesty
• convicted of a crime of dishonesty
• fined for conduct relating to a company that carries on business in the
financial service sector
•
sentenced to a prison term
• levied with a substantial fine
Please tick () ‘Yes’ or ‘No’
YES
NO
If you answered Yes to question 1, please provide full details of the matter(s) involved, any penalty imposed, the time that
has elapsed since the offence, and the age of the person when the offence was committed:
2. Are you or have you ever been bankrupt in New Zealand or elsewhere, and if
discharged from bankruptcy, how long since your discharge?
YES
NO
3. Have you at any time and under the Insolvency Act 2006 (or similar law in a
foreign country):
• entered into a composition or arrangement with your creditors?
• been subject to a Summary Instalment Order?
• filed a No Asset Procedure?
4. At any time, have you ever been disqualified from being a director, manager
or promoter of an entity as a result of a decision or order of any Court, Security
Commission, or Registrar of Companies in New Zealand or under similar overseas
jurisdiction?
5. Have you ever been disqualified under the law of a foreign country from
managing, or taking part in the management of an entity that carried on the business
or insurance or otherwise dealt in financial matters?
If you have answered Yes to questions 4, or 5, please provide details of the disqualification, including a description why,
when, and where this occurred, and the period of disqualification:
6. Are you now, or have you ever been suspended, expelled, excluded from, or
refused admission to, or been subject to disciplinary action by a professional or
industry body, or a clearing house or exchange, or been found guilty under
disciplinary action?
7. Have you ever been involved with the affairs of an entity that was expelled or
excluded from, or refused admission to a professional or industry, or a clearing house
or exchange, and engaged in conduct which caused or contributed to the entity’s
expulsion, exclusion or non-admission?
YES
NO
8. Have you ever been refused a licence or authorisation relating to a commercial
or professional activity, or have you had such a licence or authorisation revoked?
YES
NO
YES
NO
YES
NO
9. Have you ever been involved in the affairs of an entity that was refused a
license or authorisation relating to a commercial or professional activity, or had such
a licence or authorisation revoked, and engaged in conduct that caused or
contributed to the refusal or revocation of the licence or authorisation?
10. Have you ever had an appointment terminated, or resigned or asked to resign,
from a position as director or manager of, or professional service provider to an entity
in circumstances which reflected adversely on your competence, character, diligence,
honesty, integrity or judgment in discharging your responsibilities in the position?
11. Have you ever seriously or persistently failed to manage your debts or financial
affairs in accordance with your contractual or other legal obligations in circumstances
where such failure caused loss to others?
12. Were you, or did you act as, a director or manager of, or professional advisor to,
an entity (whether in New Zealand or overseas) that:
(I)
was, or later came to be, insolvent?
(II) was, or later came under insolvency administration?
(III) was, or later came under statutory or judicial management; or
(IV) failed to repay, or otherwise failed to meet its financial obligations to creditors or beneficiaries, and/or engaged in unreasonable or
unlawful conduct that caused or contributed to the insolvency,
placement under insolvency administration or statutory or judicial
management, or failure to repay or otherwise meet obligations to
creditors or beneficiaries?
13. Have you contravened any regulatory requirement or professional standard
relating to:
(i) the management of an entity; or
(ii) commercial or professional activities?
14. Has it ever been held that you were unreasonably or improperly obstructive
of, or misleading or untruthful in dealing with, or failed to comply with the lawful
direction of, the Reserve Bank (or overseas equivalent), a court, tribunal, official
inquiry, regulator, complaints handling body, dispute resolution body, or professional
or industry body?
15. Has it ever been held that you breached a fiduciary obligation or other legal
or professional obligation involving trust or conflict of interest or perpetrated or
participated in negligent, deceitful or otherwise discreditable business or
professional practices?
16. Has it ever been held that you failed to comply with the fit and proper policy
of an institution regulated under the Financial Markets Conduct Act 2013 (or similar
legislation elsewhere)?
If you answered Yes to any of the above questions 6 to 16, please provide further details:
GENERAL INQUIRIES:
YES
NO
YES
NO
17. Are you a member of any other Credit Unions/mutual/cooperative savings
and loans society?
18. Has a personal representative or trustee ever been appointed to administer
your property on the grounds of mental incapacity?
If you answered Yes to questions 17 to 18, please provide details:
19. Have you previously been employed as a staff member or director of Credit Union
or any of the Credit Union’s preceding it (e.g. Credit Union Otago, Credit
Union Southland, etc.)
If you answered Yes to question 19 please state the term (beginning and end dates) of your employment and position held:
20. (Complete this question after completing the RBNZ’s suitability notice) As a
proposed Director you are required to complete a suitability notice under section 15
of the NBDT Act stating that you have no suitability concerns or that you have 1 or
more suitability concerns. Does your suitability notice state that you have 1 or more
suitability concerns?
YES
NO
If you answered Yes to question 20 please state type of suitability concern raised in terms of the RBNZ’s “Guidance note
on suitability assessments under the Non-bank Deposit Takers Act 2013” and provide additional details relating to the
suitability concern:
I declare that:
• There is no further information (other than that provided in this declaration and in the responsible Person – Personal
Information Statement) that may be relevant to your assessment of my fitness and propriety as a responsible person;
• I hereby give my consent for CU South to obtain necessary information as to my fitness and propriety, now and in
future, as required;
• I have no actual or potential conflict of interest which might affect my proper performance of the duties of my
position for either CU South ; and,
• The answers given above, and any other information that I have given in connection with this eligibility questionnaire,
are complete and accurate as at today’s date.
I certify that in my opinion I am, in accordance with CU South’s Fit & Proper Policy, a fit and proper person to hold the
position of Director.
Name of
Applicant:
Previous Name
(if any):
Residential
Address:
Home Phone:
Work:
Mobile Phone:
Tick here if not an existing CU South Director:
Signature of
Applicant
Date:
D D M M Y Y