* 1. Have you ever been convicted of an offence in Trinidad and Tobago or elsewhere?
If yes, please give particulars.
Yes
No
* 2. Are there any criminal proceedings pending against you in Trinidad and Tobago or elsewhere?
If yes, please give particulars
Yes
No
* 3. Have any civil or administrative fines or sanctions been imposed upon you?
If yes, please give particulars.
Yes
No
* 4. Have you at anytime failed to satisfy a judgment debt under a Court Order made in
Trinidad and Tobago or anywhere else?
If yes, please give particulars.
Yes
No
* 5. Have you at any time, in Trinidad and Tobago or anywhere else been declared
bankrupt or are you the subject of any bankruptcy proceedings?
If yes, please give particulars.
Yes
No
*
6. Are you currently a Director of any company?
If yes, provide the name of the company, date and place of incorporation and the date of your appointment.
Yes
No
* 7. Have you held a senior position in a company that has gone into liquidation/ receivership within the past five (5) years?
If yes, please give particulars.
Yes
No
* 8. Have you ever been a senior officer of an entity in Trinidad and Tobago or elsewhere, that was, during your period of association, convicted of an offence?
If yes, please give particulars.
Yes
No
* 9. Have you ever been disqualified or restricted in Trinidad and Tobago or elsewhere
by a court from acting as a director of a company?
If yes, please give particulars.
Yes
No
* 10. Have you ever been dismissed or compelled to resign from any office or
Employment?
If yes, please give particulars.
Yes
No
*
11. Have you ever been refused entry to any professional membership/institution?
If yes, please give particulars.
Yes
No
* 12. Have you ever received or been exposed to any AML/CFT or compliance training?
If yes, please give particulars.
Yes
No
* 13. Have you ever been registered in any capacity under the securities law of Trinidad and Tobago or another jurisdiction?
If yes, please give particulars.
Yes
No
* 14. Has any registration identified at item 13 above been suspended, revoked, or allowed to expire?
If yes, please give particulars.
Yes
No
* 15. Is there any other information that you consider relevant to this application?
If yes, please give particular.
Yes
No
I hereby certify that the information contained in this application form and all appendices hereto attached are true and accurate to the best of my knowledge and belief.