FSC Custodian Services - NON CIS - License Application Form

THE FINANCIAL SERVICES COMMISSION APPLICATION FORM FOR CUSTODIAN SERVICES (NON-CIS) (Pursuant to Section 16 of the Financial Services Act 2007) NAME OF APPLICANT CONTACT DETAILS OF APPLICANT ADDRESS : ………………………………..…………………………………………………… …………………………………..………………………………………………… PHONE NO : ……………………………………..……………………………………………… FAX NO : ……………………………………..……………………………………………… EMAIL : ……………………………………..……………………………………………… WEBSITE : ……………………………………..……………………………………………… Date of Application Date of Receipt: FSC Reference No: Note: (i) The information/documents required vide this Application Form and Annex must not be considered exhaustive. The FSC may request for such other information as it deems necessary with respect to the Application. (ii) The FSC reserves the right to amend the Application Form and Annex to reflect any change in relevant laws, regulations, rules and policy guidelines. (iii) Additional sheet(s) may be used, if necessary, to submit the required information. FOR OFFICIAL USE Applicants Should Not Write Below This Line 2 0 2 0 FSC F S 1.7 LEGAL STATUS OF THE APPLICANT 1. APPLICANT'S DETAILS 1.1 APPLICANT IS/SHALL BE A: Tick as appropriate (3) Public Company Private Company Other (please specify) …..……..…………………… 2. CAPITAL STRUCTURE (as applicable) 2.1 Share Capital (at par value/at no par value) ** Stated Capital ………………..….. Amount to be represented at no par value …………..……….. 2.2 Types and Classes of Shares (specify whether issued and fully-paid) Number of Shares Amount^ (Rs) ………………………………………………….. …………………………………………………. ………………………………………………….. ………………………………………………….. ………………………………………………….. ………………………………………………….. ………………………………………………….. …………………. …………………. …………………. …………………. …………………. …………………. …………………. ………………………… ………………………… ………………………… ………………………… ………………………… ………………………… ………………………… ** Delete as appropriate ^ To specify, if denominated in a currency other than Mauritian rupees 3. REGISTERED OFFICE/PLACE OF BUSINESS IN MAURITIUS 3.1 ADDRESS: ….…………………...……..…………………….……..…….……………………….. ………………..……………………………....………………………..….………………………… ………………..……………………………....………………………..….………………………… PHONE /FAX /EMAIL: …….………………………………..…………….……………………… 4. DIRECTORS (as applicable) Full Name (surname in block letters) Citizen of Mtius (Y/N) Contact Details (Phone/Fax/Email) 5. SECRETARY (as applicable) Full Name Address Contact Details (Phone/Fax/Email) 6. AUDITOR Full Name Address Contact Details (Phone/Fax/Email) 7. OFFICERS (Director/ CEO/ MD/ CFO/ CFC/ General Manager/ Manager/CoSec/ Partner/ Trustee/ Compliance Officer/ MLRO/ Deputy MLRO) [as applicable] Full Name & Position (surname in block letters) Citizen of Mtius (Y/N) Contact Details (Phone/Fax/Email) 8. SUBSTANTIAL SHAREHOLDERS * (as applicable) Full Name (surname in block letters) Address Citizen of Mtius (Y/N) % Share** * As defined under the Companies Act 2001; **To also specify Types and Classes of Shares 9. ULTIMATE BENEFICIAL OWNERS* (if different from details provided under Section 8) Full Name (surname in block letters) Address Citizen of Mtius (Y/N) * Means the ultimate owners/beneficiaries of the Applicant 10. Documents to be submitted for each Controlling Shareholder and Ultimate Beneficial Owner ^ Tick as appropriate 3 10.1 Individual 10.1.1 Certified copy of National Identity Card / Valid Passport 10.1.2 Bank Reference from a recognized banking institution which has known the person for at least the last two years 10.1.3 Class of shares to be held by the person including the number of shares and respective amount 10.2 Company 10.2.1 Certified copy of Certificate of Incorporation/Registration and/or Licence 10.2.2 Certificate of Current Standing 10.2.3 Corporate Profile, Latest Annual Return and Audited Financial Statements 10.2.4 Class of shares to be held by the company including the number of shares and respective amount 10.3 Trust 10.3.1 Certified copy of Trust Deed 10.3.2 An indication of assets value held by the trust 10.3.3 Profile of the settlor/contributor, trustee and beneficiaries of the trust 10.3.4 For a discretionary trust: Confirmation that the FSC will be provided with the appropriate CDD documents on beneficiaries, as and when distributions are made 10.4 Limited Partnership 10.4.1 Certified copy of Certificate of Registration, and Good Standing of the Limited Partnership 10.4.2 Profile and latest audited financial statements of the Limited Partnership 10.5 Société 10.5.1 Certified copy of 'Statuts de Société', and Accounting Records 10.5.2 Details of the principals ^ Controlling shareholder and ultimate beneficial owner refers to any person/entity who/which is entitled to exercise or control the exercise, either directly or indirectly, of 20 per cent or more of the voting power of the Applicant. DECLARATION BY APPLICANT/APPLICANT'S REPRESENTATIVE I certify that the information furnished in this application and additional submission, as required in Annex hereto, is complete and correct to the best of my knowledge and belief. I also undertake to notify the Financial Services Commission of any material change in information/documents submitted with respect to the above. Name of Applicant/Applicant's Representative (BLOCK CAPITALS) ……………………………………………………………………….……………… Signature of Applicant/Applicant's Representative: …………….……………………………………..…… Date: .….…………..……………………..………………………………………….