Annexure A
Biodata of Directors, Shareholders, Compliance Officer
Please affix your
recent passport size
colour photograph
Full Name:
Designation: Director ( )
Shareholder ( )
Compliance Officer ( )
Any other (Please specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
______
Whether authorised signatory Yes ( ) No ( )
Date of Birth: _ _ _ _\ _ _ _ _\ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Place of Birth:
Full Address:
Country of Residence:
Phone Number (with country & area
code):
Email:
Fax Number (with country & area code):
Nationality:
Passport Details*: Number:
Date of Issue: Date of Expiry:
Source of Funds**:
Qualification(s):
T. +971 4361 1616 Floor 37, Gold Tower
F. +971 4 361 16 17 JLT Cluster I
E. info@[Link] PO Box 37736, Dubai, UAE
Work Experience (in detail):
Details of other directorships held (if any):
Membership of Professional Bodies:
Fit & Proper Questionnaire:
Kindly answer the following. If the answer is yes, please provide further details in the comment field:
No. Description Yes No Comments
Have you ever been unable to fulfill any of his
financial obligations, or gone into insolvency,
liquidation, administration or the equivalent
1 proceedings, or been subject to a judgment debt or
declared bankruptcy in the last 10 years in the UAE
or elsewhere?
Have you committed administrative violations or
criminal offenses for which final decisions were
2 issued by a governmental or regulatory authority,
inside or outside the UAE in the last 10 years?
Has any judgment or court order ever been awarded
by the courts or the prosecution against you in
relation to fidelity, fraud, cheating or otherwise which
3
would damage the reputation of the market, its
member, traders, or others?
Have you ever been accredited, licensed, or
authorized by other regulators or governmental
4
institutions, whether local or international?
been refused, or had a restriction placed on, the
right to carry on a trade, business, or profession
5 requiring a license, registration, or other permission
in the last 10 years?
Do you have direct or indirect control over a financial
6 entity?
Do you represent another person who is an UBO in
7
any Financial entity?
T. +971 4361 1616 Floor 37, Gold Tower
F. +971 4 361 16 17 JLT Cluster I
E. info@[Link] PO Box 37736, Dubai, UAE
Have you been penalized or subject to a discipline
8 order by any regulatory body (e.g., a tax authority)?
Have you ever belonged to, contributed to, or
worked for any professional, social, or charitable
9
organization?
Has your name ever been listed on the sanction lists
issued by the United Nations and other international
10 organizations, especially those concerned with anti-
money laundering and counter-terrorism funding?
Have you ever been a senior military, government
Official, a political official of any country, a senior
executive of a state-owned corporation, or an
11
immediate family member or close associate of such
a person?
Declaration:
I declare that, to the best of my knowledge and belief, having made all due inquiry, the information
given in this form, and in the documents attached is complete and correct, and will immediately
notify the Exchange of any significant changes in the information provided in this form which occur
after the date of submitting the form.
Place:
Date:
Signature:
NOTE:
1. It’s mandatory to provide all the required information.
2. Please enclose a certified true copy of the signatory’s passport
3. Please provide relevant documents as proof of the source of funds. For instance, Proof of
Source of funds/wealth can be:
▪ Proof of property sale
▪ Records of external investment
▪ Commercial loan agreement letter
▪ Audited Financial Statements
▪ Bank Statements
▪ Written confirmation from a qualified accountant/lawyer
▪ Grant of Probate/Copy of Will
▪ Salary certificate
▪ Any other accepted documents
T. +971 4361 1616 Floor 37, Gold Tower
F. +971 4 361 16 17 JLT Cluster I
E. info@[Link] PO Box 37736, Dubai, UAE