Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1698831454697.pdf (Saint Vincent and the Grenadines)
FIT AND PROPER QUESTIONNAIRE FOR DIRECTORS/SENIOR MANAGEMENT/OWNER A Fit and Proper Questionnaire must be completed by each person who effectively directs or controls the company or business such as Directors, Senior Management and Owners.

Tick here to confirm that the listed documents are being submitted with this form: 1.

Original Copy of Police Record 2.

Copies of two (2) form of identification 3.

Proof of address in the form of a utility bill, bank statement or government document 4.
Copy of Curriculum Vitae (CV) and qualifications () () () () 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 1.First Name: 2.

Middle Name: 3.

Surname: 4.

Country of birth: 5.

ID#, Passport #, Driver’s License# [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 ( Attach copy of CV and qualifications): 13.

Have you ever had a change of name?

(If yes, please give details and attach relevant deed poll): 14.
Position held within the entity, duration and the list of responsibilities: PART III GOOD REPUTATION AND CHARACTER (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.
b.

Have you ever been convicted in St. Vincent and the Grenadines, or elsewhere, for any offence involving money laundering, terrorist financing, fraud or dishonesty?

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 or occupation?

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

Yes [ ] No [ ] i.

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

Yes [ ] No [ ] j.

Are you a Director/ Owner of any other Company/Business?

k. Are you presently or do you expect to be engaged in any litigation in St. Vincent and the Grenadines or elsewhere?
Yes [ ] No [ ] 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