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APPLICATION FORMS AND NOTICES (AFN) -AUT – IND 1

For DFSA use only

Form AUT – IND 1

Application for authorisation Authorised Individual status

Name of individual

Name of Authorised/applicant firm

DFSA Reference Number (If applicable)

Firms are requested to contact the supervision department of the DFSA (switchboard +971 (0)4 362 1500 or [email protected]) before considering completing an application

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mailto:[email protected]


Purpose of this form

This form must be submitted by an applicant firm or an Authorised Firm applying for Authorised Individual status for an individual who is to carry out one or more Licensed Functions, as defined in the GEN module of the DFSA Rulebook.

Before submitting an application to the DFSA , the applicant firm or Authorised Firm must make all reasonable enquires as to the individual’s fitness and propriety to carry our the relevant Licensed Functions.

In some cases the DFSA may require additional information in order to complete the processing of this application. If this is necessary the DFSA will contact the person identified as the firm’s relevant contact to obtain such additional information.

An Authorised Firm applying to extend or vary the scope of an existing Authorised Individual’s status should use form AUT-IND2 instead of this form.

An Authorised Firm applying to withdraw an existing Authorised Individual’s status should use form AUT-IND3 instead of this form.

Contents

Section Title

1 General information

2 Licensed functions

3 Education and professional qualifications

4 Employment history

5 Other personal registrations

6 Professional memberships

7 Other holdings

8 Referees

9 Fit and proper questionnaire

10 Attachments

11 Declarations

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Notes for completing this form

Defined terms are identified throughout this application form by the capitalisation of the initial letter of a word or phrase and are defined in the Glossary module (GLO) of the DFSA’s Rulebook.

Unless otherwise specified, applicant refers to the individual for whom Authorised Individual status is being sought.

Unless otherwise specified, Authorised Firm refers to the firm on whose behalf the applicant will be carrying out the Licensed Functions and includes, for the purposes of this application, a firm applying for authorisation to carry on Financial Services.

Prior to completion of this form Authorised Firms should read the relevant sections of the GEN module of the DFSA Rulebook applying to Authorised Individuals.

All sections of the form must be completed. Questions must be answered fully and the use of abbreviations or acronyms should be avoided or defined.

Do not leave any questions blank. If a question is not applicable this should be indicated in the response section. Failure to answer questions or provide full responses will delay the progress of the application.

Answers must be typed in electronic format and the form must be signed by a Director/Partner of the applicant or, in the event that, for example, the applicant has yet to be incorporated, the Director who will be authorised in due course to sign on behalf of the applicant. Versions of this form on the DFSA’s website are in PDF format. Editable Microsoft Word versions can be obtained from the DFSA.

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SECTION 1 - GENERAL INFORMATION

About the Authorised Firm

1.1 Name of Authorised Firm

1.2 DFSA Licence number(If applicable)

1.3 Applicant’s contact person for this application

1.4 Contact telephone number

1.5 Contact E-mail

1.6 Contact address

About the applicant

1.7 Title (Mr, Mrs etc.)

1.8 Full name as it appears in the applicant’s passport

1.9 Other names

1.10 Has the applicant ever used any previous names? Yes No

If No please go to question 1.11.

If Yes, please provide the following information:

State previous names

Date name changed

Reason for change of name

1.11 Date of birth (DD/MM/YYYY)

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1.12 Place of birth

1.13 Passport(s) number(s)

1.14 Please state the country(ies) and place(s) of issue of the applicant’s passport(s).

Please attach a copy of all passports held by the applicant, including copies of any current visas.

1.15 Has the applicant previously held Authorised Individual status with the DFSA?

Yes No

If Yes, please indicated the applicant’s previous individual reference number with the DFSA

Citizenship

1.16 Please provide details of all citizenship/residency held by the applicant.

Country/Territory

Status(National/resident/domicile/Other[please specify])

Relevant dates (if applicable)

National identification number

National identification source(ID card/visa/passport etc.)

Country/territory

Status(National/resident/domicile/Other [please specify])

Relevant dates (if applicable)

National identification number

National identification source(ID card/visa/passport etc.)

Please use additional sheets if required

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Contact details

1.17 Residential address

1.18 Dates resident at above address:

From To

1.19 Previous address if less than 3 years at the above address

1.20 Residential telephone number (include country and area codes)

1.21 Residential fax number (include country and area codes)

1.22 Contact e-mail address

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SECTION 2 - LICENSED FUNCTIONS

Mandatory appointments

Note: Mandatory Licensed Functions are defined at GEN 7.5 of the DFSA Rulebook.

2.1 Will the applicant be carrying out a mandatory Licensed Function? Yes No

If No, please go to question 2.2.If Yes, please complete the following questions detailing the mandatory Licensed Functions the applicant will carry out.

2.1.1 Senior Executive Officer (SEO)

Licensed Director

Licensed Partner

Senior Manager

Please indicate at what level the SEO will be Licensed.

Note: Please see GEN module Rule 7.4.2 (b)

Please confirm the SEO will be ordinarily resident in the UAE. Yes NoNote: Please see GEN module Rule 7.5.2

2.1.2 Finance Officer

Licensed Director

Licensed Partner

Senior Manager

Please indicate at what level the Finance Officer will be Licensed.

Note: Please see GEN module Rule 7.4.5

2.1.3 Compliance Officer

Licensed Director

Licensed Partner

Senior Manager

Please indicate at what level the Compliance Officer will be Licensed.


Please confirm the Compliance Officer will be ordinarily resident in the UAE. Yes NoNote: Please see GEN module Rule 7.5.2

2.1.4 Money Laundering Reporting Officer (MLRO)

Licensed Director

Licensed Partner

Senior Manager

Please indicate at what level the MLRO will be Licensed.


Please confirm the MLRO will be ordinarily resident in the UAE. Yes NoNote: Please see GEN module Rule 7.5.2

Other Licensed Functions

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2.2 Please indicate the Licensed Functions to be carried out by the applicant.

2.2.1 Licensed Director

2.2.2 Licensed Partner

2.2.3 Senior Manager

2.2.4 Responsible Officer

The applicant’s role and experience

2.3 Job title within the Authorised Firm.

2.4 Commencement date of Licensed Functions(dd/mm/yyyy).

2.5 Please attach a detailed job description for the applicant, which should include the activities of the Licensed Function to be carried out. The job description should clearly detail all the responsibilities of the role; Please indicate if the role is full time or not; and Where the role is not full time, please detail how much of the applicant’s time will be

devoted to carrying out the Licensed Function role.

2.6 Please describe in detail how the Authorised Firm has determined that the applicant is competent to carry out the Licensed Functions.

Technical competence

(Please include the relevant qualifications and training specific to the proposed Licensed Function on which you have determined the candidate’s competence for the Licensed Functions to be carried out.)

Relevant experience (Please include the relevant experience specific to the proposed Licensed Function on which you have determined the candidate’s competence for the Licensed Functions to be carried out.)

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SECTION 3 - EDUCATION & PROFESSIONAL QUALIFICATIONS

Higher education

3.1 List all higher education degrees and diplomas held.

Name and location of university/ institution Details of degree/diploma

Dates of study

From To

Professional qualifications

3.2 List any professional qualifications held.

Full name of institute Full name of qualification heldDates of study

From To

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Other relevant qualifications

3.3 List any other qualifications held by the applicant which are relevant to their role.

Full name of institute Full name of qualification heldDates of study

From To

Copies of certificates

3.4 Please attach copies of all certificates listed in section 3.

3.5 Are there any qualifications listed in questions 3.1 to 3.3 for which certificates are unavailable and copies cannot be supplied?

Yes No

If Yes please detail below what due diligence and checks the Authorised Firm has carried out to verify the applicant’s qualifications.

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SECTION 4 - EMPLOYMENT HISTORY

4.1 Please provide full details of your career covering the last ten years.

Note: The full ten year period must be detailed. Any gaps between employment or education of more than one month, must be included and relevant details provided (e.g. career break, unemployment, etc.).

Dates Employment (Specify employer)

Study (Specify institute)

Other(Please specify)From

dd/mm/yyTo

dd/mm/yy

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Employment history

4.2 Please provide the following details for all periods of employment detailed in the ten year period at 4.1 above, starting with your current or most recent employment.

Employment 1

Full name of employer.

Full address of employer.

Nature of business.

Contact person within employer.

Position/title of contact person.

Contact telephone number.

Contact fax number.

Contact E-mail.

If applicable state the employer’s Financial Services Regulator.

The applicant’s position/title with the employer.

Nature of employment(Employed/self employed/contractor).

Please provide details of any regulated activities carried out by the applicant.

Reason for leaving employment.

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Employment 2



Nature of business.




Contact fax number.

Contact E-mail.






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Employment 3



Nature of business.




Contact fax number.

Contact E-mail.






Please use additional sheets as required and submit as an attachment

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SECTION 5 - OTHER PERSONAL REGISTRATIONS

5.1 Has the applicant held or been granted, in a personal capacity, any licence, registration or organisation by any Financial Services Regulator not stated elsewhere in this form?

Yes No

If Yes please provide full details below

Full name of Financial Services Regulator

Nature of license, registration or authorisation held

Scope of activity permitted by Licence, registration or authorisation held

Relevant dates of licence, registration or authorisation held From To

Please use additional sheets as required

5.2 Is the applicant applying as an outsourced individual (ie. CO, MLRO, or FO) Yes No

If Yes, please provide details below of other Firms that the applicant has been Authorised to carry on such service to, and/or has a pending application to carry on such service.

Please Detail the following:a) The full name of the Firm;b) The category of the Firm if it is a DFSA regulated Firm;c) The status of the Firm (Pending, In-Principle, or Authorised);d) Your application status ( Pending, or Authorised);e) The actual/proposed working hours per month.

Firm Name CAT (if applicable)

Firm Status Applicants Application Status

Actual/Proposed Working Hours (Hrs / Month)

Please use additional sheets as required

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Please provide an explanation to demonstrate the competence and capability of the applicant in carrying out his/her function adequately in light of other commitments as mentioned above.

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SECTION 6 - PROFESSIONAL MEMBERSHIPS

6.1 List all current professional memberships

Full name of organisation Location/jurisdictionDate of

admission/ membership

Brief explanation of the organisation

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SECTION 7 - OTHER HOLDINGS

7.1 Please provide a summary of any Controller positions, Directorships or Partnerships held or that have been held in the past 10 years.

Please details the following:a) The full name of the entity;b) The business operations of the entity; c) A description of your involvement with the entity;d) The percentage shareholding in the entity; ande) Any relationship, either direct or indirect that the entity has with the Authorised Firm

submitting this application.

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SECTION 8 - REFEREES

8.1 Please provide details of two referees who will vouch for the applicant’s integrity and professional experience. The DFSA may contact these referees before the application for Authorised Individual status is determined.

Note: At least one of the referees must be independent of both the Authorised Firm submitting this application and the applicant (i.e. not a relative or family member).

Full name of referee

Profession/occupation

Nature of relationship to applicant

Telephone number(including country and area code)

E-mail address

Contact address

Explain the basis on which the referee is able to provide this reference and vouch for the applicant’s integrity and professional experience

Full name of referee

Profession/occupation

Nature of relationship to applicant

Telephone number(including country and area code)

E-mail address

Contact address

Explain the basis on which the referee is able to provide this reference and vouch for the applicant’s integrity and professional experience

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SECTION 9 - FIT & PROPER QUESTIONNAIRE

9.1 Please complete the following questionnaire in relation to the applicant.Answers must be provided to every question.

Has the applicant: Yes No

(i) been convicted or found guilty by any court of competent jurisdiction in respect of any offence, other than a minor road traffic offence?

(ii) ever been the subject of disciplinary procedures by a government body or agency or any self Regulatory organisation or other professional body?

(iii) contravened any provision of Financial Services legislation or of Rules, Regulations, statements or principle or codes of practice made under or by a Financial Services Regulator or other supervisory body?

(iv) been refused or restricted the right to carry on a trade, business or profession requiring a licence, registration or other authority?

(v) been dismissed or requested to resign from any office of employment?

(vi) been concerned with the management of a Body Corporate which has been or is currently the subject of an investigation into a allegation of misconduct or malpractice?

(vii) received an adverse finding in a civil action by any court of competent jurisdiction of fraud, misfeasance, or other misconduct, whether in connection with the formation or management of a corporation or otherwise?

(viii) received an adverse finding in an agreed settlement in a civil action by any court or tribunal of competent jurisdiction resulting in an award against an individual in excess of $10,000 or awards that total more than $10,000?

(ix) been the subject of an order of disqualification as a Director or otherwise to act in the management or conduct of the affairs of a corporation by a court of competent jurisdiction or Regulator?

(x) been a Director, or Partner or concerned in the management of a company or Partnership which has gone into insolvent liquidation whilst the individual was connected with that company, Partnership or within one year of such a connection?

(xi) been the subject of complaint in connection with a Financial Service or Ancillary Service which relates to his integrity, competence or financial soundness?

(xii) been censured, disciplined, publicly criticised by or the subject of a court order at the instigation of a Financial Services Regulator or any officially appointed inquiry?

If you have answered Yes to any questions, please provide appropriate details of the matter below.

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SECTION 10 - ATTACHMENTS

RelevantQuestion Attachment Required

Attachment Included

Yes To Follow N/A

1.14 Copies of all passports held including any current visas

2.9 Copy of the applicant’s detailed job description

3.4 Copies of ALL certificates listed in questions

Other, please specify

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SECTION 11 - DECLARATIONS

Declaration by the applicant

1. I declare that, to the best of my knowledge and belief, having made due enquiry, the information given in this form is complete and correct. I understand that it is an offence under Article 66 of the Regulatory Law 2004 to provide to the DFSA any information which is false, misleading or deceptive or to conceal information where the concealment of such information is likely to mislead or deceive the DFSA.

2. I declare that, I am fit and proper to perform the Licensed Functions to which this application relates and, in the event of a failure on my part to remain fit and proper, I shall notify the DFSA of such fact as reasonably practical.

3. I declare my understanding that the DFSA may request more detailed information (including but not limited to, personal, educational, employment and financial information) should it be deemed necessary to assess my fitness and propriety adequately. I consent to the DFSA contacting any previous employers, educational institutions, professional organisations or any other organisation, to verify any information contained in this form.

4. For the purposes of complying with DIFC Data Protection Law 2007, I understand that any Personal Data provided to the DFSA will be used to discharge its regulatory functions under the Regulatory Law 2004 and other relevant legislation and may be disclosed to third parties for those purposes.

Signature of applicant Date

Name of applicant

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Declaration by the Authorised Firm

1. I declare that, the applicant’s competence has been assessed in accordance with the requirements of the DFSA Rulebook and I declare that the applicant is competent to perform the Licensed Functions to which this application relates.

2. I declare that, to the best of my knowledge and belief, having made due enquiry into the applicant’s background and qualifications, the information given in this form is complete and correct. I understand that it is an offence under Article 66 of the Regulatory Law 2004 to provide to the DFSA any information which is false, misleading or deceptive or to conceal information where the concealment of such information is likely to mislead or deceive the DFSA.

3. I declare that to the best of my knowledge and belief, having made due enquiry, the applicant is fit and proper to perform Licensed Functions to which this application relates.

4. I confirm that I have the authority to make this application, to declare as specified above and sign this form for, or on behalf of, the Authorised Firm.

Signature of Senior Executive Officer or Compliance Officer

Date

Name of Senior Executive Officer or Compliance Officer

Please return the completed form to:

Dubai Financial Services AuthorityLevel 13, The GatePO Box 75850Dubai, UAE

Firms are advised to retain a copy of the form and all relevant attachments for their records.

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