| 1. Application is made for registration under the Securities Industry Act, 1995 in the
category of: |
|
| {application_category_details} |
| 2. The Applicant maintains accounts at the following bank(s):
(State Bank and Branches through which business is transacted) |
| {bank_information} |
| Financial Year End: {year} |
| 3. Is Applicant applying for registration of any Branch Office (If so, state addresses of Branch Office(s))?: {registering_office} |
| {branch_information} |
| 4. Has the Applicant, or to the best of the Applicant's information and belief has any affiliate of the Applicant: |
| (a) been registered in any capacity under the Securities Industry Act, 1995(If yes state particulars)?: {been_registered} |
| {registering_info} |
| (b) applied for registration, in any capacity, under the Securities Industry Act, 1995(If yes state particulars)?: {registering} |
| {been_registered_info} |
| 5. Is the Applicant, or to the best of the Applicant's information and belief is any affiliate of the Applicant, now, or has any such person or company been |
| (a) registered or licensed in any capacity in any other country which requires registration or licensing to deal or trade in securities (If yes state particulars)?: {is_registered} |
| {is_registered_details} |
| (b) registered or licensed in any other capacity in Trinidad and Tobago under any legislation which requires registration or licensing to deal with the public in any capacity? (e.g. as an insurance agent, real estate agent, private investigator, mortgage broker, etc. If yes state particulars)?: {is_registering} |
| {registering_details} |
| (c) refused registration or a licence mentioned in 5(a) or (b) above or has any registration or licence been suspended or cancelled in any category mentioned in 5(a) or (b) above (If yes state particulars)?: {registration_refused} |
| {registration_refused_details} |
| (d) denied the benefit of any exemption from registration provided by the Securities Industry Act, 1995 (If yes state particulars)?: {denied_benefit} |
| {denied_benefit_details} |
| 6. Is the Applicant, or to the best of the Applicant's information and belief is any affiliate of the Applicant, now, or has any such person or company been - |
| (a) member of any Stock Exchange, Investment Dealers Association, Investment Bankers, or similar organization, in any country (If yes state particulars)?: {is_member} |
| {is_member_details} |
(b) refused membership in any Stock Exchange, Investment Dealers Association, Investment Bankers, or similar organization, in any country (If yes state particulars)?: {refused_member}
|
| {refused_member_details} |
(c) suspended as a member of any Stock Exchange, Investment Dealers Association, Investment Bankers, or similar organization, in any country (If yes state particulars)?: {suspend_member}
|
| {suspend_member_details} |
| 7. Has the Applicant, or to the best of the Applicant's information and belief has any affiliate of the Applicant, operated under, or carried on business under, any name other than the name shown in this application (If yes state particulars)?: {has_alias} |
| {name_alias} |
| 9. Set out in the space provided, the name of the Applicant, or the name of and position held by each director, officer or partner of the Applicant seeking or holding
registration. NOTE: an underwriter may not trade with the public· Name of persons who will act (In addition to last name, Office held give full first and middle names) |
| {other_applicants} |
| 8. Has the Applicant, or to the best of the Applicant's information and belief, has any affiliate of the Applicant- |
| (a) ever been convicted under the laws of any country, excepting minor traffic offences (If yes state particulars)?: {was_convicted} |
| {conviction_details} |
| there currently an outstanding charge or indictment against the affiliate(If yes state particulars)?: {outstanding_charges} |
| {charges_details} |
| (b) ever been the defendant or respondent in any proceedings in any civil court in any jurisdiction in any part of the world wherein fraud was alleged?: {is_fraud} {fraud_details} |
| (c) at any time declared bankruptcy, or made a voluntary assignment in bankruptcy (If yes state particulars and also attach a certified copy of discharge)?: {bankrupt} |
| {bankruptcy_details} |
| (d) ever been refused a fidelity/surety bond (If yes state particulars)?: {refused_bond} |
| {refusal_bond_details} |
| Question 8(a) refers to all Laws, e.g. Criminal, Customs, Liquor, etc. of any state or country, in any part of the world. You are not required to disclose any convictions for which a pardon has been granted under the Laws of Trinidad and Tobago, and which pardon has not been revoked. |
| 10. Attach and mark as an exhibit a completed form for each director, officer or partner of the Applicant seeking or holding registration. |
| Date: {date} |
| Signature: _____________________________________________________________________ |
