Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1698831471957.pdf (Saint Vincent and the Grenadines)
FIT AND PROPER QUESTIONNAIRE FOR COMPLIANCE OFFICERS Pursuant to Regulation 26 of the Anti-Money Laundering and Terrorist Financing Regulations 2014, a service provider, with the exception of a sole trader, shall appoint an individual approved by the FIU as its AML/CFT Compliance Officer.
In selecting a Compliance Officer, the service provider must ensure that:  The proposed Compliance Officer has sufficient seniority in the organization/business; and  The individual has timely and unfettered access to all records that are necessary for the purpose of performing his or her functions as AML/CFT Compliance Officer.

In the case of a sole trader, he or she is the Compliance Officer in respect of the NRSP but is still required to complete this form.

PART I – GENERAL INFORMATION 1.


Name of Legal Entity/Individual: 2.

Certificate of Registration#: 3.

Nature of Business: Real Estate Agent () Car dealer() Attorney/ Notary() Accountant/Auditor() Jeweller() Casino() PART II – PERSONAL DETAILS OF DESIGNATED OFFICER 1.First Name: 2.

Middle Name: 3.

Surname: 4.

Country of birth: 5.

ID#, PP#, DL# [List any two (2) and attach copies] 6.

Citizenship: 7.

Date of birth: 8.

Email address: 9.

Residential Address: 10.


Mailing Address (If different from Residential Address): 11.Telephone #: Work: Home: Mobile: 12.

Level of education: Secondary, Tertiary, Postgraduate etc.

Kindly state any professional qualifications/ memberships: e.g.

CAMS.

( Attach copy of qualifications) 13.

Have you ever had a change of name?

(If yes, please give details and attach relevant deed poll etc.

): 14.
): 14.

Position held within the entity (Attach job description or organizational chart): PART III FIT AND PROPER REQUIREMENTS (answer all questions) [Where the response is yes, you MUST give particulars on a separate page] a.

Have you ever been charged in St. Vincent and the Grenadines or elsewhere for any criminal offence, regulatory offence or criminal misconduct?

b.

Have you ever been convicted in St. Vincent and the Grenadines, or elsewhere, for any offence?
c. Have you ever been a principal officer of an entity that was, during your period of association, charged or convicted of an offence or sanctioned by a Regulatory Body or Supervisor?

Yes [ ] Yes [ ] Yes [ ] No [ ] No [ ] No [ ] d. Have you at any time, in St. Vincent and the Grenadines or anywhere else been declared bankrupt or are you the subject of any bankruptcy proceedings?
Yes [ ] No [ ] e. Have you at any time failed to satisfy a judgment debt under a Court Order made in St. Vincent and the Grenadines or anywhere else?

Yes [ ] No [ ] f. Have you ever been disqualified or restricted in St. Vincent and the Grenadines or elsewhere by a court from acting as a director of a company?

Yes [ ] No [ ] g. Have you ever been refused entry to any profession?

Yes [ ] No [ ] h. Have you ever been dismissed or compelled to resign from any office or employment?

Yes [ ] No [ ] i.
Yes [ ] No [ ] i.

Have you ever received any AML/CFT or compliance training?

Yes [ ] No [ ] PART IV DECLARATION I declare that to the best of my knowledge and belief that all of the information I have given in this application is correct.
I am aware that under regulation 12 of the Anti-Money Laundering and Terrorist Financing (Non- Regulated Service Providers) Regulations 2022, it is an offence to: a) provide any information, make any representation or submit any document that I know, suspect or have reasonable ground to suspect to be false or materially misleading or do not believe to be true; or b) recklessly provide any information, make any representation or submit any document or return that is false or materially misleading.
I am aware that a non-regulated service provider who commits this offence is liable – (a) on summary conviction to a fine of $50,000 or to imprisonment for two years or to both; or (b) on conviction on indictment to a fine of $100,000 or to imprisonment for two years or to both.

Print name: _______________________________ Signature: _________________________________ Position: __________________________________ Date: ________day of ______________20_______ FOR OFFICIAL USE ONLY