Application Form for an individual responsible for the management of an Electronic Money Institution The Electronic Money Regulations 2011

1 Personal identification details

Financial Services Auth
EMD Individual Form

Application Form for an individual responsible for the management of an Electronic Money Institution

The Electronic Money Regulations 2011

Name of individual (to be completed by applicant firm)

     

Full name of applicant firm (as entered in 2.1)

     

Firm reference number (as entered in 2.2)

     

Important information you should read before completing this form

Please keep a copy of the forms you complete and any supporting documents you include with this application for your future reference.

It is important that you provide accurate and complete information, and disclose all relevant information. If you do not, you may be committing a criminal offence and it may increase the time taken to assess your application.

The FCA has produced notes which will assist both the applicant and the individual in answering the questions in this form. Please read these notes, which are available on the FCA’s website at www.fca.org.uk . Both the applicant and the individual will be treated by the FCA as having taken these notes into consideration when completing their answers to the questions in this form.

Contents of this form

1	Personal identification details	3
2	Firm identification details	5
3	Employment details	6
4	Fitness and propriety	8
5	Supplementary information	16
6	Declarations and signatures	17

Application for Authorisation as a

Payment Institution
Financial Services Authority

Application for Authorisation as a

Payment Institution
Filling in the form

1 If you are using your computer to complete the form:

• 
  use the TAB key to move from Question to Question and press SHIFT TAB to move back to the previous Question.
  

2 If you are filling in the form by hand:

• 
  use black ink; and
  
• 
  write clearly.
  

3 If you think a Question is not relevant to you, write 'not applicable' and explain why.

4 If you leave a Question blank without telling us why, we will have to treat the application as incomplete. This will increase the time taken to assess your application.

5 If there is not enough space on the forms, you may need to use separate sheets of paper. Clearly mark each separate sheet of paper with the relevant Question number.

6 If the EMD Individual Form is not part of a new application for registration as an Electronic Money Institution, please email a scanned (PDF) copy of the completed form to:
[e-mail]

If the EMD Individual Form is part of a new application for registration or authorisation as an Electronic Money Institution this should be posted along with all the other relevant EMD application forms (as applicable), to us at:

Permissions Department
The Financial Conduct Authority
25 The North Colonnade
Canary Wharf
London
E14 5HS

1.8 Previous name

     

1.9 Date of name change (dd/mm/yyyy)

     

     

/

     

     

/

     

     

     

     

1.10a Nationality

     

1.10b Passport number

     

1.11 Place of birth

     

1.12 Private address

Business address	     
Postcode	     

1.9 Dates resident at this address (mm/yyyy)

     

     

/

     

     

     

     

To Present

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

3 1	Personal identification details

1.1a FCA Individual Reference Number (IRN) (if individual is already registered with the FCA)

     

b OR name of previous regulatory body

     

c AND previous reference number

     

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

     

1.3 Surname

     

1.4 ALL forenames

     

1.5 Name commonly known by

     

1.6 Date of birth (dd/mm/yyyy)

     

     

/

     

     

/

     

     

     

     

1.7 National Insurance number

     

1.8 Previous name

     

1.9 Date of name change (dd/mm/yyyy)

     

     

/

     

     

/

     

     

     

     

1.10 Nationality

     

1.11 Passport number (if National Insurance number not available)

     

1.12 Place of birth

     

1.13 Private address

Private address	     
Postcode	     

Date resident at this address (mm/yyyy)

From

     

     

/

     

     

     

     

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

1.14 Previous address 1

Private address	     
Postcode	     

Dates resident at this address (mm/yyyy)

     

     

/

     

     

     

     

To

     

     

/

     

     

     

     

Previous address 2

Private address	     
Postcode	     

Dates resident at this address (mm/yyyy)

     

     

/

     

     

     

     

To

     

     

/

     

     

     

     

2	Firm identification details

2.1 Name of applicant firm making the application

     

2.2 FCA Firm Reference Number (FRN)

     

2.3 Who should the FCA contact at the applicant firm in relation to this application?

Name

     

Position

     

Telephone

     

Fax

     

Email

     

3	Employment history

N.B. A full five-year employment history must be provided & ALL gaps must be accounted for. Failing to provide this may delay the processing of the application (refer to the relevant notes in section 4)

Employment details (1)

3.1

Current position
Period From	mm/yy		To	mm/yy
Nature of employment	a) Employed b) Self-employed c) Unemployed d) In full-time education If c or d is ticked, please give details
	     
Name of employer	     
Last known address of employer	     
Previous/other names of employer	     
Nature of business	     
Is/was employer regulated by a regulatory body?	 No  Yes Please give the name of the regulatory body
		     
Position held	     
Responsibilities	     

Employment details (2)

3.2

Previous position
Period From	mm/yy			To	mm/yy
Nature of employment	a) Employed b) Self-employed c) Unemployed d) In full-time education If c or d is ticked, please give details
	     
Name of employer	     
Last known address of employer	     
Previous/other names of employer	     
Nature of business	     
Is/was employer regulated by a regulatory body?	 No  Yes Please give the name of the regulatory body
		     
Position held	     
Responsibilities	     
Reason for leaving	 a) Resignation  b) Redundancy  c) Retirement  d) Termination/dismissal  e) End of contract  f) Other Please specify
			     

4	Fitness and Propriety

In answering these questions, the individual and applicant/firm are expected to give the words (in the questions) the widest possible interpretation. Remember, the FCA treats non-disclosure very seriously.

Part A – Criminal proceedings

In answering the questions in Part A, you should include matters whether in the United Kingdom or overseas. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, if the individual is subject to the law of England and Wales, they must disclose spent convictions and spent cautions (other than protected convictions and cautions). By virtue of the Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Order 2013 and the Rehabilitation of Offenders (Exceptions) Order (Northern Ireland) 1979, if the individual is subject to the law of Scotland or Northern Ireland, they must disclose spent convictions (other than a protected conviction).
For the avoidance of doubt, references to the legislation above are references to the legislation as amended.

4.1

i Has the EMD Individual ever been convicted of any criminal offence? (You should include any conviction of an offence for which the EMD Individual received an absolute or conditional discharge. You should include traffic offences only if they resulted in a ban from driving or involved driving without insurance)?

  No   Yes

ii Has the EMD Individual ever received a caution in relation to any criminal offence?

  No   Yes

iii Is the EMD Individual the subject of any ongoing criminal investigation?

  No   Yes

iv Has the EMD Individual been ordered to produce documents pursuant to any ongoing criminal investigation or been the subject of a search (with or without a warrant) pursuant to any ongoing criminal investigation?

  No   Yes

(You should include all matters even where the EMD Individual themselves was not the subject of the investigation)

4.2 Is the EMD Individual currently the subject of any proceedings relating to any criminal offence?

  No   Yes

Please revert to the guidance notes for the meaning of ‘position of influence’ in the context of the questions in this form.

4.3 Has any firm at which the EMD Individual holds or has held a position of influence ever:

i been convicted of any criminal offence?

  No   Yes

ii been summonsed, charged with or otherwise prosecuted for any criminal offence?

  No   Yes

iii been the subject of any criminal investigation which has not resulted in a conviction?

  No   Yes

iv 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?

  No   Yes

You should include all matters arising during the EMD Individual’s association with that firm and for a period of one year after the EMD Individual ceased to be associated with the firm. (You should include all matters even where the charge, prosecution or investigation has not resulted in a conviction and, in respect of 4.3(iv), even where the firm itself was not the subject of the investigation.) However, you are not required to disclose details of any individuals who were subject to criminal investigations, prosecutions, summons or other criminal proceedings (other than ongoing ones).

4.4 Is any firm at which the EMD Individual holds or has held a position of influence currently the subject of any criminal proceedings or the subject of a criminal investigation? (You should include all matters arising during the EMD Individual’s association with that firm and for a period of one year after the EMD Individual ceased to be associated with the firm.)

  No   Yes

4.5 If you have answered yes to any of the questions in Part A above, please give full details in section 5. Tick this box to confirm that you have provided full details, including reason(s), date(s) and duration as applicable.

  Yes

Part B – Civil proceedings

In answering the questions in Part B you should include matters in the United Kingdom or overseas.

4.6 Has the EMD Individual ever been:

i adjudged by a court liable for any fraud, misfeasance, negligence, wrongful trading or other misconduct?

  No   Yes

ii the subject of a judgment debt or award?

  No   Yes

iii party to any other civil proceedings which resulted in a finding against the EMD Individual (other than a judgment debt or award referred to at 4.6 (ii) above)? (You should include, for example, injunctions and employment tribunal proceedings.)

  No   Yes

(You should include all County Court Judgment(s) (‘CCJs’) made against the EMD Individual, whether satisfied or not. Please include in section 5:

• 
  the sum and date of all judgment debts or CCJs (whether satisfied or not); and
  
• 
  the total number of all CCJs ordered.)
  

4.7 Is the EMD Individual currently:

i a party to any civil proceedings?

  No   Yes

ii aware of anybody’s intention to begin civil proceedings against them? (You should include any ongoing disputes whether or not such dispute is likely to result in a finding against the EMD Individual or the order of a judgement debt.)

  No   Yes

4.8 Has any firm at which the EMD Individual holds or has held a position of influence ever been:

i adjudged by a court liable for any fraud, misfeasance, wrongful trading or other misconduct?

  No   Yes

ii party to any other civil proceedings which resulted in a finding against the firm?

  No   Yes

iii the subject of a judgement debt or award other than in relation to matters mentioned at 4.8(i) and 4.8(ii) above? (You should include all CCJs made against the firm, whether satisfied or not.)

  No   Yes

(Where the EMD individual no longer holds a position of influence at the firm, consider whether matters have arisen within one year after the EMD Individual ceased to be associated with the firm. Include all matters which have arisen within this period).

4.9 Is any firm at which the EMD Individual holds or has held a position of influence currently:

i a party to civil proceedings?

  No   Yes

ii aware of anyone’s intention to begin civil proceedings against them?

  No   Yes

(You should include all matters arising during the EMD Individual’s association with that firm and for a period of one year after the EMD Individual ceased to be associated with the firm.)

4.10 Has the EMD Individual ever (tick all that apply)

i) filed for bankruptcy or had a bankruptcy petition served on him /her?

  No   Yes

ii) been adjudged bankrupt?

  No   Yes

iii) been the subject of a bankruptcy restrictions order (including an interim bankruptcy restrictions order) or offered a bankruptcy restrictions undertaking?

  No   Yes

iv) made any arrangements with creditors, for example a deed of arrangement or an individual voluntary arrangement (or in Scotland a trust deed)?

  No   Yes

v) had assets sequestrated? or

  No   Yes

vi) been involved in any proceeding relating to the above matters even if such proceedings did not result in the making of any kind of order or result in any kind of agreement?

  No   Yes

4.11 Is the EMD Individual currently involved in any proceedings in relation to any of the matters set out in 4.10(i) – (vi) above (you should include where the EMD Individual is in the process of entering into any kind of agreement in favour of the EMD Individual's creditors)?

  No   Yes

Please specify in section 5 whether any bankruptcy orders made have been discharged.

4.12 Does the EMD Individual have any outstanding financial obligations connected with regulated activities (including any activities regulated by the FCA or any other regulatory body), which the EMD Individual has carried on in the past?

  No   Yes

4.13 Has any firm at which the EMD Individual holds or has held a position of influence at any time during and within one year of the EMD Individual’s involvement:

i been put into liquidation?

  No   Yes

ii been wound up (whether compulsorily or voluntarily)?

  No   Yes

iii ceased trading?

  No   Yes

iv had a receiver or administrator appointed?; or

  No   Yes

v entered into any voluntary arrangement with its creditor?

  No   Yes

4.14 If you have answered yes to any of the questions in Part B above please give full details in section 5. Tick this box to confirm that you have provided full details, including reason(s), date(s) and duration as applicable.

  Yes

Part C – Business and employment matters

In answering the questions in Part C you should include matters in the United Kingdom or overseas.

4.15 Has the EMD Individual ever been:

i dismissed;

  No   Yes

ii asked to resign or agreed to resign; or

  No   Yes

iii suspended

  No   Yes

from any profession, vocation, office, employment, position of trust, fiduciary appointment or similar, whether or not remunerated?

4.16 Has the EMD Individual ever been:

i disqualified from acting as a director or similar position?

  No   Yes

ii the subject of any proceedings of a disciplinary nature (whether or not the proceedings resulted in any finding)?

  No   Yes

iii the subject of any investigation which might lead to or might have led to disciplinary proceedings?

  No   Yes

iv notified of any potential proceedings of a disciplinary nature?

  No   Yes

v the subject of any allegations of malpractice or misconduct in connection with any business activities?

  No   Yes

4.17 If you have answered yes to any of the questions in Part C above, please give full details in section 5. This at a minimum should include the reason(s), date(s) and duration as applicable. Tick this box confirm that you have provided full details:

  Yes

Part D – Regulatory matters

Please revert to the guidance notes for the meaning of ‘regulatory body’ and ‘authorisation’ in the context of the question below.

In answering the questions in Part D you should include matters whether in the United Kingdom or overseas.

4.18 In relation to activities regulated by the FCA or any other regulatory body, has the EMD Individual ever:

i been refused, had revoked, restricted or terminated, any authorisation granted or required by any regulatory body?

  No   Yes

ii been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action by any regulatory body?

  No   Yes

iii received a warning that such disciplinary or intervention action may be taken (whether public or privately)?

  No   Yes

iv been the subject of an investigation by any regulatory body, whether or not such investigation resulted in a finding?

  No   Yes

v resigned or ceased to act whilst under investigation by any such body or been required to resign or cease acting by any regulatory body?

  No   Yes

vi decided, after making an application for any authorisation granted by any regulatory body, not to proceed with it?

  No   Yes

vii provided payment services or distributed or redeemed e-money on behalf of a regulated firm under any contractual agreement where that agreement was terminated by the regulated firm?

  No   Yes

4.19 Has any firm of which the EMD Individual held a position of influence during the EMD Individual’s association with that firm as well as for a period of one year after the EMD Individual ceased to be associated with it ever:

i been refused, had revoked, restricted or terminated, any authorisation granted or required by any regulatory body?

  No   Yes

ii been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action by any regulatory body?

  No   Yes

iii received a warning that such disciplinary or intervention action may be taken (whether public or privately)?

  No   Yes

iv been the subject of an investigation by any regulatory body, whether or not such investigation resulted in a finding?

  No   Yes

v been required or requested to produce documents or any other information to any regulatory body?

  No   Yes

vi ceased operating whilst under investigation by any such body or been required to cease operating by any regulatory body?

  No   Yes

vii decided, after making an application for any authorisation granted by any regulatory body, not to proceed with it?

  No   Yes

viii provided payment services or distributed or redeemed e-money on behalf of a regulated firm under any contractual agreement where that agreement was terminated by the regulated firm?

  No   Yes

4.20 In relation to activities regulated by the FCA or any other regulatory body has the EMD individual ever:

i been found to have carried on activities for which authorisation or registration is required by the FCA (or any other regulatory body) without the requisite authorisation/registration?

  No   Yes

ii been investigated for the possible carrying on of activities for which authorisation or registration is required by the FCA (or any other regulatory body) without the requisite authorisation/registration, whether or not such investigation resulted in a finding?

  No   Yes

iii been found to have performed a controlled function (or an equivalent function requiring approval by the FCA or any other regulatory body) without the requisite approval?

  No   Yes

iv been investigated for the possible performance of a controlled function (or an equivalent function requiring approval by the FCA or any other regulatory body) without the requisite approval, whether or not such investigation resulted in a finding?

  No   Yes

v been the subject of a disqualification direction under section 59 of the Financial Services Act 1986 or a prohibition order under section 56A of the Financial Services and Markets Act 2000, or received a warning notice proposing that such a direction or order be made?

  No   Yes

4.21 Has any firm of which the EMD Individual is or has held, a position of influence during the EMD Individual’s association with that firm as well as for a period of one year after the EMD Individual ceased to be associated with it ever:

i been found to have carried on activities for which authorisation by or registration with the FCA is required (or any activity requiring authorisation from any other regulatory body) without the requisite authorisation/registration?

  No   Yes

ii been investigated for the possible carrying on of activities requiring authorisation by or registration with the FCA (or activities requiring authorisation from any other regulatory body) without the requisite authorisation/registration, whether or not such investigation resulted in a finding?

  No   Yes

iii been found to have performed a controlled function (or an equivalent function requiring approval by the FCA or any other regulatory body) without the requisite approval?

  No   Yes

iv been investigated for the possible performance of a controlled function (or an equivalent function requiring approval by the FCA or any other regulatory body) without the requisite approval, whether or not such investigation resulted in a finding?

  No   Yes

v been found to have failed to comply with an obligation under the Electronic Money Regulations 2011 or Payment Services Regulations 2009 to notify us of the identity of a person acting in a position of influence over its electronic money or payment services business?

  No   Yes

4.22 If you have answered yes to any of the questions in Part D above, please give full details in section 5. This at a minimum should include the reason(s), date(s) and duration as applicable. Tick this box confirm that you have provided full details.

 Yes

Part E – Other matters

4.23 Is the EMD individual aware of any business interests, employment obligations, or any other circumstances which may affect the performance of the role at the firm?

  No   Yes

4.24 The EMD Individual needs to demonstrate that they possess the appropriate knowledge and experience to perform payment services. You must therefore include in section 5 a description of the EMD Individual’s relevant:

i training;

  Yes

ii knowledge; and

  Yes

iii experience

  Yes

including dates and time periods.

4.25 Have you submitted the EMD individual’s CV to support the information supplied in 4.24?

  No   Yes

4.26 If you have answered yes to 4.23 please give full details in section 5. Tick this box to confirm that you have provided full details.

  No   Yes

5	Supplementary information

5.1 If there is any other information the individual or the firm considers may be relevant to the application, it must be included here.

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

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.

NOTE: Full details must be provided here if there were any issues that could affect the Fitness and Propriety of the individual that arose when leaving an employer listed in section 3 or if relevant question(s) have been answered ‘yes’ in section 4.

Question	Information
     	     

Please indicate how many additional sheets are being submitted

     

6	Declarations and signatures

Declaration of Individual

Knowingly or recklessly giving the FCA (or providing to another person to give to the FCA) information which is false or misleading in a material particular, is a criminal offence (regulation 114 of the Payment Services Regulations 2009) and may lead to disciplinary sanctions or other enforcement action by the FCA.

It should not be assumed that information is known to the FCA merely because it is in the public domain or has previously been disclosed to the FCA or another regulatory body, and the applicant is not entitled to assume that, in assessing this application, the FCA will check its existing records in respect of (or for information relating to) the applicant or persons connected to it.

For the purposes of complying with the Data Protection Act 1998, any personal information provided to us will be used to discharge our functions under the Electronic Money Regulations 2011 and other relevant legislation; it may be disclosed to third parties for those purposes and/or where there is an applicable gateway permitting disclosure (i.e. specific circumstances in which the FCA is permitted to disclose confidential information to a third party).

With reference to the above, the FCA may seek to verify the information given in this Form including answers pertaining to fitness and propriety. This may include a credit reference check and/or a Disclosure Barring Service (DBS) check.

I authorise the FCA to make such enquiries and seek such further information as it thinks appropriate in the course of verifying the information given in this Form. I understand I may be selected to undergo a DBS search to determine whether any criminal records are held in relation to me and that the FCA may wish to disclose the results of that search to the firm submitting this application.

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.

6.1 Individual’s full name

     

6.2 Signature

Date (dd/mm/yyyy)

     

     

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/

     

     

     

     

Declaration of Applicant Firm

It is a criminal offence (under Regulation 66) to knowingly or recklessly give us information which is false or misleading in a material particular. If necessary, appropriate professional advice should be sought before supplying information to us.

All information that the FCA might reasonably consider relevant to this notification should be supplied to the FCA. It should not be assumed that information is known to the FCA merely because it is in the public domain or has previously been disclosed to the FCA or another regulatory body, and the applicant is not entitled to assume that, in assessing this application, the FCA will check its existing records in respect of (or for information relating to) the applicant or persons connected to it.

In making this application the applicant firm / PI believes on the basis of due and diligent enquiry that the individual is a fit and proper person. The firm also believes, on the basis of due and diligent enquiry, that the individual is competent to fulfil the duties required.

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.

I confirm that I have authority to make this application, and sign this Form, on behalf of each PI identified in section 2. I also confirm that a copy of this Form, as submitted to the FCA, will be sent to each of those PIs at the same time as submitting the Form to the FCA.

6.3 Name of the applicant firm submitting the application

     

6.4 Name of person signing on behalf of the applicant firm

     

6.5 Job title

     

6.6 Signature

Date (dd/mm/yyyy)

     

     

/

     

     

/

     

     

     

     

FCA  EMD Individual Form  Release 4  January 2016 page