Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697641119566.pdf (Antigua and Barbuda)
Antigua and Barbuda Financial Services Regulatory Commission The Corporate Management and Trust Service Providers Act, 2008 [Section 6 and 7] as Amended SCHEDULE A(1) – FORM (2): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR RENEWAL OF 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: registryandCMTSPt@fsrc.gov.ag Website: http://www.fsrc.gov.ag SCHEDULE A (1) – FORM (2): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE OR RENEWAL OF LICENCE SECTION I.

INSTRUCTIONS FOR COMPLETING SCHEDULE A(1) – FORM (2): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR RENEWAL OF LICENCE 1.

This application must be submitted with all supporting documentation listed at the end of the form.

2.
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 Licensee: 3.

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

Website address, if any: SECTION III.

PERSONAL DETAIL 5.

During the last year, have you had your name changed?
Fax Number: E-mail Address  Proof of Address attached  Yes (Give reasons for the change)  No 6.

Previous name: 7.

Date of change: 8.

Marital Status: Place of Change:  Single  Married  Separated z:\cm&tsp forms\edited\schedule a(1) form(2)- cmtsp renewal of licence application by attorney or professional.docx Last Revised: 6/25/2020 12:28:05 PM  Divorced Page 2 of 9 SCHEDULE A (1) – FORM (2): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE OR RENEWAL OF LICENCE 9.
Provide the address of your residence for the last year if there was a change: Address (1): Start Date:  Proof of Address attached End Date: SECTION IV.

EDUCATION/QUALIFICATION/EMPLOYMENT HISTORY 10.

Provide updated educational information (BSc., MBA, LLC, etc.)

if there was a change:  Academic Qualifications attached Name of Institution: Address: Business Number: Degree Awarded: E-mail Address: Date Awarded: 11.
List any professional certificates issued by any recognized/authorized institution which you currently hold such as CAMS, ACCA, CMA, CPA, CGA, STEP, if acquired during the past year:  Professional Qualifications attached Name of Institution: Address: Telephone Number: Certificate Issued: E-mail Address: Date Issued: 12.
List membership in professional associations if you enrolled during the past year:  Membership Information attached Name of Institution: Address: Telephone Number: Membership Number: E-mail Address: Status of Membership: 13.

During the last year, 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: Telephone Number: Date Issued: Reasons for Revocation/Suspension: E-mail Address: Type of Licence Issued: Date Revoked/Suspended: SECTION V. REPUTATION AND CHARACTER 14.

Are any criminal charges pending against you?

 Yes (Give details)  No 15.

Are you the subject of any regulatory investigation or is any such investigation pending?
z:\cm&tsp forms\edited\schedule a(1) form(2)- cmtsp renewal of licence application by attorney or professional.docx Last Revised: 6/25/2020 12:28:05 PM  Yes (Give details)  No Page 3 of 9 SCHEDULE A (1) – FORM (2): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE OR RENEWAL OF LICENCE 16.

Has there been any adverse finding or settlement against you in civil proceedings during the last year?

 Yes (Give details)  No 17.


Were you suspended or dismissed from any office or asked to resign during the last year?

 Yes (Give details)  No 18.
(a) Were you 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 are you the subject of any disciplinary  Yes (Give details)  No proceeding of any governmental or state regulatory agency during the last year ?
(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 during the last year ; and if so did the entity become bankrupt or insolvent while you were in  Yes (Give details)  No that position?

19.
19.

Has the certificate of authority or licence to do business for 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 during the last year?

 Yes (Give details)  No 20.

Were you 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 during the last year?
 Yes (Give details)  No 21.

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 body or company or towards any members thereof during the last year?

 Yes (Give details)  No 22.


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  Yes (Give details)  No or omission by you during the last year?
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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 24.


(a) Were you 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, in the past year?

(b) Are you aware of any such proceedings pending?

 Yes (Give details)  No  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 25.

Are you a director of any company, partnership, corporate body or any other business organization engaged in a similar business?

Name of Company: Address: Type of Business: Telephone Number: Start date:  Yes (Give detail)  No Contact Person: E-mail Address: End Date: 26.
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, during the past year?
 Yes (Give details)  No Name of Company: Address: Type of Business: Telephone Number: Start date: Give Details: Contact Person: E-mail Address: End Date: SECTION VII.

NATURE OF THE BUSINESS 27.
Complete the table below by indicating with tick marks the activity or activities which the licensee proposes to carry on z:\cm&tsp forms\edited\schedule a(1) form(2)- cmtsp renewal of licence application by attorney or professional.docx Last Revised: 6/25/2020 12:28:05 PM Page 5 of 9 SCHEDULE A (1) – FORM (2): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE OR RENEWAL OF LICENCE 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;  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 shareholder services 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; 28.
Indicate the Class of Licence under the Corporate Management and Trust Service Providers Act required for the new year:  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.
 Class C 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; z:\cm&tsp forms\edited\schedule a(1) form(2)- cmtsp renewal of licence application by attorney or professional.docx Last Revised: 6/25/2020 12:28:05 PM Page 6 of 9 SCHEDULE A (1) – FORM (2): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE OR RENEWAL OF LICENCE 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. 29.

Name of external auditor: 30.

Level of insurance coverage:  Schedule E attached  Evidence of insurance/bond attached SECTION VIII.

SEGREGATED ACCOUNT INFORMATION 31.


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 licensee intends to open such accounts: (Please attach additional accounts on a separate sheet).
 Clients’ account letter(s) attached Name of Bank: Address: Contact Person: Telephone Number: Account Name: Name of Bank: Address: Contact Person: Telephone Number: Account Name: E-mail Address: Fax Number: Account Number: E-mail Address: Fax Number: Account Number: 32.

Name(s) and address(es) of banks with whom office accounts are maintained (as appropriate), or at which the licensee intends to open such accounts.
List the licensee’s main bankers first:  (Bank Reference Letter Attached) Name of Bank: Address: Contact Person: Telephone Number: Account Name: E-mail Address: Fax Number: Account Number: SECTION IX.

COMPLIANCE PROGRAM INFORMATION 33.

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

 Yes (Compliance Manual attached)  No 34.

The compliance manual addresses the requirements captured in the Corporate Management and Trust Service Providers Act.
z:\cm&tsp forms\edited\schedule a(1) form(2)- cmtsp renewal of licence application by attorney or professional.docx Last Revised: 6/25/2020 12:28:05 PM  Yes  No Page 7 of 9 SCHEDULE A (1) – FORM (2): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE OR RENEWAL OF LICENCE 35.

The AML/CFT policies and procedures are fully implemented.

36.

The licensee has conducted a risk assessment of its services.

37.

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

38.
38.

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

SECTION X.

DECLARATION  Yes  No  Yes  No  Yes (Training Schedule attached)  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\edited\schedule a(1) form(2)- cmtsp renewal of licence application by attorney or professional.docx Last Revised: 6/25/2020 12:28:05 PM Page 8 of 9 SCHEDULE A (1) – FORM (2): APPLICATION BY ATTORNEY OR PROFESSIONAL FOR LICENCE OR RENEWAL OF LICENCE SECTION XI.

DOCUMENTATION WHICH FORMS PART OF THIS APPLICATION Documents 1.

Licensee’s Address Information 2.

Residential Address Information 3.

Academic Qualifications 4.


Professional Qualifications 5.

Membership Information 6.

Schedule E 7.

Insurance and/or Bond 8.

Client Letter of Authorisation 9.

Client account letter 10.

Bank Reference Letters 11.

Compliance Manual 12.

Training Schedule 13.

Licence Fee Notes An original copy of a utility bill or similar document showing proof of principal address of the licensee’s place of business if the address has changed in the past year.
An original copy of a utility bill or similar document showing proof of the licensee’s residential address if the address has changed in the past year.

Certified proof of stated higher academic qualifications such as copies of Masters, Bachelors degree, etc., if the licensee has acquired additional academic qualifications in the past year.

Certified proof of professional qualifications, CPA, CGA, CPE, etc., if the licensee has acquired additional professional qualifications in the past year.
Certified proof of membership to professional bodies if the licensee has acquired additional membership in the past year.

Notice of Auditor must be completed and approved annually by the Commission.

Evidence of insurance and/or bond as appropriate (Class B, Class C and Class E Licensee) must be provided for the new year.

Client Agreements/Administration Agreements/Terms for licensees who operate clients’ accounts, if there were changes in the last year.
Letters from the banks confirming that accounts are held in trust on behalf of the licensee’s clients, if there were changes in the last year.

Confirming establishment of accounts in the licensee’s name and the account numbers, if there were changes in the last year.
A copy of the licensee’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, if there were changes in the last year.
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 for the upcoming year.

Cheque payable to “the FSRC” for the licence fees upon receipt of confirmation of renewal of licence.

Attached              SECTION XII.


ADMINISTRATION - FOR FSRC USE ONLY Date: Received by (employee’s name): Decision taken by the Commission: z:\cm&tsp forms\edited\schedule a(1) form(2)- cmtsp renewal of licence application by attorney or professional.docx Last Revised: 6/25/2020 12:28:05 PM Page 9 of 9