Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697632674354.pdf (Antigua and Barbuda)
Antigua and Barbuda Financial Services Regulatory Commission The Corporate Management and Trust Service Providers Act, 2008 [Section 6] as Amended SCHEDULE A(1) – FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE Please forward completed form with any supporting material to: Manager, IBCs & CMTSPs Financial Services Regulatory Commission P.O.
Box 2674 Royal Palm Place Friars Hill Road St. John’s, Antigua Tel: (268) 481-1170 ● Fax: (268) 463-0422 Email: registryandCMTSP@fsrc.gov.ag Website: http://www.fsrc.gov.ag SCHEDULE A (1) - FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE SECTION I.

INSTRUCTIONS FOR COMPLETING SCHEDULE A(1) – FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE 1.

This application must be submitted with all supporting documentation listed at the end of the form and a non-refundable application fee.
2.

This form can be downloaded from the Commission’s website in Adobe Acrobat format, and completed online.

Alternatively, the form may be printed and completed with the use of a typewriter, or black ink and BLOCK CAPITALS or typescript.

3.

Any information provided on additional sheets must be signed and dated.

4.

Where there is a question which is not applicable, please write “N/A” beside the question.

5.

All dates must be completed in the form: Day/Month/Year.

6.
6.

Questions left unanswered or which do not disclose all information will affect the Commission’s assessment, and may result in significant delays in processing.

7.

A licence to engage in corporate management services is valid for a period not exceeding twelve (12) months from the date on which it takes effect and must be prominently displayed on the premises where the business of the corporate management service provider is carried on.
If the licensee has a website or other presence on the internet, the licensee’s licence number and class of licence should be prominently displayed on each web page.

8.

In accordance with Section 27(2), a person commits an offence if, for the purposes of obtaining a licence, he or she makes any representation that he or she knows to be false or does not believe to be true.
That person will be liable on summary conviction, to a fine not exceeding one hundred thousand United States Dollars (US$100,000); or to a term of imprisonment not exceeding twelve (12) months.

1.

Date of Application: SECTION II.

CONTACT DETAILS 2.

Name of Applicant: 3.

Principal Office Information: Business Address: Contact Person: Telephone Number: Mobile Number: 4.

Website address, if any: SECTION III.

PERSONAL DETAIL 5.

Have you ever had your name changed?


 Application Fee attached  Identity Information attached  Proof of address attached Fax Number: E-mail Address:  Yes (Give reasons for the change)  No 6.

Previous names: 7.

Date of change: Place of Change: z:\cm&tsp forms\schedule a(1) form(1) - cmtsp application by attorney or professional.docx Last Revised: 6/26/2020 10:18:53 AM Page 2 of 10 SCHEDULE A (1) - FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE 8.

Gender: 9.

Date of birth: 10.


Citizenship: Place of birth: 11.

Marital Status:  Single 12.

List your residence for the last ten (10) years:  Married  Separated  Male  Female  Passport Biography Page attached  Divorced  Proof of current address attached Address (1): Address (2): Address (3): Address (4): Start Date: Start Date: Start Date: Start Date: End Date: End Date: End Date: End Date: SECTION IV.

EDUCATION/QUALIFICATION/EMPLOYMENT HISTORY 13.


Education: Name of Institution, Address, Degree awarded (BSc., MBA, LLC, etc.)

 Academic Qualifications Attached Institution (1): Address: Business Number: Degree Awarded: Institution (2): Address: Business Number: Degree Awarded: E-mail Address: Date Awarded: E-mail Address: Date Awarded: 14.
List any professional certificates issued by any recognized/authorized institution which you currently hold or have held in the past such as CAMS, ACCA, CMA, CPA, CGA, STEP.

(State the date the certificate was issued, issuer of certificate):  Professional Qualifications Attached Institution (1): Address: Telephone Number: Certificate Issued: Institution (2): Address: Telephone Number: Certificate Issued: E-mail Address: Date Issued: E-mail Address: Date Issued: 15.
List membership in professional societies and associations:  Membership Information Attached Institution (1): Address: Telephone Number: Membership Number: E-mail Address: Status of Membership: z:\cm&tsp forms\schedule a(1) form(1) - cmtsp application by attorney or professional.docx Last Revised: 6/26/2020 10:18:53 AM Page 3 of 10 SCHEDULE A (1) - FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE Institution (2): Address: Telephone Number: Membership Number: E-mail Address: Status of Membership: 16.
During the last ten (10) years, have you ever been refused a professional, occupational or vocational licence by any public or governmental licensing agency or regulatory authority, or has any such licence held by you ever suspended or revoked?

 Yes (Give details)  No Licensing Agency: Address: Contact Person: E-mail Address: Date Issued: Reasons for Revocation/Suspension: Telephone Number: Type of Licence Issued: Date Revoked/Suspended: 17.
Name of last employer:  Curriculum Vitae attached  Employment Reference attached Employer : Address: Contact Person: Telephone Number: Title/Position: Employed From : E-mail Address: Fax Number: Type of Business: Employed To: Reasons for Leaving:  Resignation  End of Contract  Retirement  Dismissal SECTION V. REPUTATION AND CHARACTER  Police Certificate attached 18.

Are any criminal charges pending against you?


 Character Reference attached  Other  Financial Reference attached  Yes (Give details)  No 19.

Are you the subject of any regulatory investigation or is any such investigation pending?

 Yes (Give details)  No 20.

Has there been any adverse finding or settlement against you in civil proceedings?

 Yes (Give details)  No 21.

Have you ever been suspended or dismissed from any office or asked to resign?
 Yes (Give details)  No z:\cm&tsp forms\schedule a(1) form(1) - cmtsp application by attorney or professional.docx Last Revised: 6/26/2020 10:18:53 AM Page 4 of 10 SCHEDULE A (1) - FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE 22.
(a) Have you ever been convicted or had a sentence imposed or suspended or had pronouncement of a sentence suspended or pardoned for conviction of or pleaded guilty or nolo contendere to any information or indictment charging any felony, or charging a misdemeanour involving embezzlement, theft, larceny, or fraud, or charging a violation or any corporate securities statute or any international financial services statutes, money laundering statutes, or have been the subject of any disciplinary proceeding of any governmental or state regulatory agency?
 Yes (Give details)  No (b) Have you ever acted in a similar position for another entity registered under the laws of any jurisdiction providing similar services as defined in the Act; and if so did the entity become bankrupt or insolvent while you were in that position?

 Yes (Give details)  No 23.


Has the certificate of authority or licence to do business of any of the international financial services entity/entities of which you were an officer or director or key management person ever been suspended or revoked while you occupied such position?

 Yes (Give details)  No 24.

Have you ever been disqualified from acting as a director of a company, or from acting in the management or conduct of the affairs of the company, partnership or unincorporated company?
 Yes (Give details)  No 25.

Have you in the connection with the formation or management of any body corporate, partnership, or unincorporated institution been adjudged by a court civilly liable for any fraud, misfeasance or other misconduct by you towards such a  Yes (Give details)  No body or company or towards any members thereof?

26.
26.

Have you, your company or your employer previously dealt on a regular basis with any person carrying on a relevant activity (incorporations, directorship services, trust services, registration of companies, etc.)

who has, to your knowledge, at any time indicated that he is unwilling to effect further transactions with you, your company or your employer, by reason of any act or omission by you?

 Yes (Give details)  No 27.


Do you (in your capacity or through any entity controlled by you) have outstanding debt of any amount sixty (60) or more days in arrears?

 Yes (Give details)  No 28.

(a) Have you ever been adjudged by a court, your estate sequestrated, or entered into any compromise with creditors, or are you currently the subject of bankruptcy proceedings or proceedings for the sequestration of your estate?
 Yes (Give details)  No z:\cm&tsp forms\schedule a(1) form(1) - cmtsp application by attorney or professional.docx Last Revised: 6/26/2020 10:18:53 AM Page 5 of 10 SCHEDULE A (1) - FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE (b) Are you aware of any such proceedings pending?

 Yes (Give details)  No (c) Have you ever failed to satisfy any debt adjudged due and payable by you as a judgment-debtor under an order of the court?

 Yes (Give details)  No SECTION VI.


RELATED OR OTHER INTERESTS 29.

Are you a director of any company, partnership, corporate body or any other business organization engaged in a  Yes (Give details)  No similar business?

Company (1): Address: Type of Business: Telephone Number: Start date: Company (2): Address: Type of Business: Telephone Number: Start date: Contact Person: E-mail Address: End Date: Contact Person: E-mail Address: End Date: 30.
Have you ever been an officer, director, trustee, investment committee member, key employee, or controlling stockholder of any international financial services entity/entities which, while you occupied any such position or capacity with respect to it, become bankrupt or insolvent or was placed under supervision or in receivership, rehabilitation, liquidation or conservatorship?
 Yes (Give details)  No Company: Address: Type of Business: Telephone Number: Start date: Give Details: Contact Person: E-mail Address: End Date: SECTION VII.

NATURE OF THE BUSINESS 31.

Complete the table below by indicating with tick marks the activity or activities which the applicant proposes to carry on within or from Antigua and Barbuda for which a licence under the Corporate Management and Trust Service Providers Act is required.
Additionally, indicate in the box, to the right, the number of activities, to date, where applicable:  The administration of corporate management for profit or reward in or from within Antigua and Barbuda; z:\cm&tsp forms\schedule a(1) form(1) - cmtsp application by attorney or professional.docx Last Revised: 6/26/2020 10:18:53 AM Page 6 of 10 SCHEDULE A (1) - FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE  The carrying on of corporate management services in or from Antigua and Barbuda, including on-line corporate management services;  The registration, incorporation or management and administration of international business corporations incorporated or existing under the International Business Corporations Act Cap.
222; Indicate the number of IBCs currently under management;  The registration, incorporation or management and administration of companies incorporated or registered as external companies under the Companies Act 1995; Indicate the number of companies currently under management;  The registration or management and administration of international limited liability companies under the International Limited Liability Companies Act; Indicate the number of companies currently under management;  The registration or management and administration of companies registered or incorporated under the International Foundation Act; Indicate the number of companies currently under management;  The provision of registered agent and registered office services for IBCs, external companies; LLCs; and Foundations;  The provision of director or officer services for IBCs, external companies; LLCs; and Foundations; Indicate the number;  The provision of nominee shareholders for IBCs, external companies; LLCs; and Foundations; Indicate the number;  The preparation and filing of statutory documents on behalf of IBCs, external companies; LLCs; and Foundations;  The provision of asset management services not otherwise regulated by the Commission or other Authority;  The provision of manager or the officer services for corporations and IBCs, external companies; LLCs; and Foundations;  The provision of partners for partnerships registered under any law in force in Antigua and Barbuda;  Acting as protector of a foundation registered under the International Foundations Act; Indicate the number of companies;  Acting as custodian of bearer shares; Indicate the number of companies;  Signatory authority or other control over accounts or assets of an Entity; Indicate the number of companies;  Other administrative, secretarial or clerical services for corporations and IBCs, external companies; LLCs; and Foundations; 32.
Indicate Class of Licence under the Corporate Management and Trust Service Providers Act required:  Class A Licence  Class B Licence Entity incorporation, registration or organization; Preparing and filing statutory documents on behalf of the Entity; Acting as registered agent for an Entity; Providing registered offices in Antigua and Barbuda for Entities; and Other administrative, secretarial or clerical services for Entities which do not include a signatory authority or other control.
Entity incorporation, registration or organization; Preparing and filing statutory documents on behalf of the Entity; Acting as registered agent for an Entity; Providing registered offices in Antigua and Barbuda for Entities; Other administrative, secretarial or clerical services for Entities; Signatory authority or other control over accounts or assets of an Entity; Acting as a director, manager, shareholder, member or officer of Entities; and Acting as a Protector for a trust or foundation.
z:\cm&tsp forms\schedule a(1) form(1) - cmtsp application by attorney or professional.docx Last Revised: 6/26/2020 10:18:53 AM Page 7 of 10  Class C Licence SCHEDULE A (1) - FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE Entity incorporation, registration or organization; Preparing and filing statutory documents on behalf of the Entity; Acting as registered agent for an Entity; Providing registered offices in Antigua and Barbuda for Entities; Other administrative, secretarial or clerical services for Entities; Signatory authority or other control over accounts or assets of an Entity; Acting as a director, manager, shareholder, member or officer of Entities; Acting as a Protector for a trust or foundation; The provision of financial or asset management services not otherwise regulated by the Commission or another Authority; and Acting as a trustee of a trust or member of a foundation council.
 Class D Licence  Class E Licence Acting as a custodian of bearer shares.

 Providing any service under Class A and Class D.  Providing any service under Class B and Class D.  Providing any service under Class C and Class D. 33.

Date of commencement of service(s): 34.

Financial year of applicant: 35.

Name of external auditor: 36.


Level of insurance coverage held or proposed:  Audited business plan/financial statement attached  Schedule E attached  Evidence of insurance/bond attached SECTION VIII.

SEGREGATED ACCOUNT INFORMATION 37.


Clients’ money accounts are managed  Yes (Clients’ authorization attached)  No If “yes” state the name(s) and address(es) of the banks with whom such accounts are maintained, or with whom the applicant intends to open such accounts: (Please attach additional accounts on a separate sheet).
 Clients’ account letter(s) attached Bank Name (1): Address: Contact Person: Telephone Number: Account Name: Bank Name (2): Address: Contact Person: Telephone Number: Account Name: E-mail Address: Fax Number: Account Number: E-mail Address: Fax Number: Account Number: 38.

Name(s) and address(es) of banks with whom office accounts are maintained (as appropriate), or at which the applicant intends to open such accounts.
List the applicant’s main bankers first:  (Bank Reference Letter Attached) Bank Name (1): Address: Contact Person: Telephone Number: Account Name: E-mail Address: Fax Number: Account Number: z:\cm&tsp forms\schedule a(1) form(1) - cmtsp application by attorney or professional.docx Last Revised: 6/26/2020 10:18:53 AM Page 8 of 10 SCHEDULE A (1) - FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE Bank Name (2): Address: Contact Person: Telephone Number: Account Name: E-mail Address: Fax Number: Account Number: SECTION IX.
COMPLIANCE PROGRAM INFORMATION 39.

The applicant complies with the Money Laundering Prevention Act and the Prevention of Terrorism Act.

 Yes (Compliance Manual attached)  No 40.

The compliance manual addresses the requirements captured in the Corporate Management and Trust  Yes  No Service Providers Act.

41.

The applicant has documented AML/CFT policies and procedures.

42.

The AML/CFT policies and procedures are fully implemented.

43.
43.

The applicant has conducted a risk assessment of its services.

44.

The applicant has an AML/CFT training program in place for staff.

45.

The applicant has a designated compliance officer.

46.

The applicant screens its customers against established databases such as OFAC.

47.

The applicant has an independent AML audit review program in place.

SECTION X.
SECTION X.

DECLARATION  Yes  No  Yes  No  Yes  No  Yes (AML training schedule attached)  No  Yes (Schedule B attached)  No  Yes  No  Yes  No DECLARATION: This declaration must be signed by the declarant.

I hereby certify that I am acting on my own behalf and that all the information provided with and within this form and any other document provided in support of said form is true and correct to the best of my knowledge and belief.
I further undertake to inform the Commission without delay of any changes to the information supplied with and within this form.

I hereby understand and consent that the Financial Services Regulatory Commission (“Commission”) may wish to make enquiries both now and on a continuous basis to satisfy itself as to my initial and continuing fitness and properness.
I authorize the bank named in this Questionnaire, together with any other person, body or institution (including the police) which the Commission may approach, to provide such information as the Commission believes may be relevant to its assessment.
Declarant’ Name: Declarant’s Title/Position: Signature: Date: z:\cm&tsp forms\schedule a(1) form(1) - cmtsp application by attorney or professional.docx Last Revised: 6/26/2020 10:18:53 AM Page 9 of 10 SCHEDULE A (1) - FORM (1): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE SECTION XI.

DOCUMENTATION WHICH FORMS PART OF THIS APPLICATION Documents 1.

Application Fee 2.

Identification Information 3.

Applicant’s Address Information 4.

Passport Information 5.

Residential Address Information 6.


Academic Qualifications 7.

Professional Qualifications 8.

Membership Information 9.

Curriculum Vitae 10.

Employment Reference 11.

Police Certificate 12.

Character Reference 13.

Financial Reference 14. Business Plan/Financial Statements 15.

Schedule E 16.

Insurance and/or Bond Certified proof of professional qualifications, CPA, CGA, CPE, etc.

Notes A onetime non-refundable application fee of US$1,000, payable to the Financial Services Regulatory Commission.
A certified copy of two (2) of the following: social security card, driver’s licence, voter’s registration card or other form of official picture identification.

An original copy of a utility bill or similar document showing proof of principal address of the applicant’s place of business.

A certified copy of the biographical passport page showing the photograph of the individual.

Attached     An original copy of a utility bill or similar document showing proof of the applicant’s residential address.
 Certified proof of stated higher academic qualifications such as copies of Masters, Bachelors degree, etc.

         Original copy of police certificate from Antigua and Barbuda and last country of residence if living in Antigua and Barbuda for less than ten (10) years.

A letter of character reference from an individual who can satisfy the Commission that the applicant has never been convicted of a serious crime or any offence involving dishonesty.
A letter of financial reference from an individual who can satisfy the Commission that you have conducted your financial affairs with integrity.

A business plan (with projections spanning a minimum period of two (2) years) for applicants with newly established businesses or the last two (2) previous years audited financial statements for applicants that are already in operation.

Notice of Auditor must be completed.


Recent curriculum vitae listing current and previous employment history and educational information.

A letter of reference from last employer, if employed in current position for less than ten (10) years.

Certified proof of membership to professional bodies.

Evidence of insurance and/or bond as appropriate (Class B, Class C and Class E Licensee) must be provided in the name of the applicant, upon issuance of the licence.

17.
17.

Client Letter of Authorization Client Agreements/Administration Agreements/Terms for applicants who operate clients’ accounts.

18.

Client account letter Letters from the banks confirming that accounts are held in trust on behalf of the applicant’s clients.

19.

Bank Reference Letters 20.

Compliance Manual 21.

Training Schedule Confirming establishment of accounts in the applicant’s name along with the associated account numbers.
A copy of the applicant’s Compliance Manual, out lining the organization’s anti-money laundering policies and procedures, the prevention of terrorism, ongoing training policies and procedures, independent audit review policies, the role of the compliance officer and compliance policies in place relevant to applicable laws and regulations governing corporate management and service providers.
A description of the staff training which is in place or to be instituted to ensure compliance with the Money Laundering Prevention Act, the Prevention of Terrorism Act, and Money Laundering Regulations and Guidelines and relevant to applicable laws and regulations governing corporate management and service providers.

22.
22.

Schedule B (1)/Letter of Engagement Biographical Affidavit of Director, Manager or Officer of the Applicant for the applicant’s compliance officer on staff or a letter of engagement for the applicant’s Compliance Officer that is on retainer.

23.

Licence Fee Cheque payable to “the FSRC” for the licence fees upon receipt of confirmation of approval of licence.

SECTION XII.
SECTION XII.

ADMINISTRATION - FOR FSRC USE ONLY Date: Received by (employee’s name): Decision taken by the Commission: z:\cm&tsp forms\schedule a(1) form(1) - cmtsp application by attorney or professional.docx Last Revised: 6/26/2020 10:18:53 AM Page 10 of 10         