Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696586170423.pdf (Vanuatu)
VANUATU GOVERNMENT – Corporate Services La Casa D’Andrea Building, Lini Highway, Private Mail Bag 9012, Port Vila, Vanuatu Telephone: (+678) 33010 Email: CIRCorporate@vanuatu.gov.vu Website: http://customsinlandrevenue.gov.vu PERSONAL INFORMATION FORM Pursuant to paragraphs 9(4) (c) and 9(5) (b) of the Anti-Money Laundering & Counter-Terrorism Financing Act No.
13 of 2014 (as amended) (the AML&CTF Act), a key person within the reporting entities as stipulated under section 2 of the said Act is required to meet the fit and proper criteria prescribed by the Anti-Money Laundering & Counter-Terrorism Financing Regulation (as amended).

The AML&CTF Act defines a “key person” as a beneficial owner, owner, controller, director or manager of the reporting entity.
IMPORTANT: Please note that any false or misleading declaration is an offence as per section 32B of the AML&CTF Act.

FIT & PROPER DECLARATION OF A KEY PERSON 1.

Full name as it appears in your valid passport: __________________________________ ____________________________________________________________________________ 2.

State any aliases (other names you are known by): ________________________________ ____________________________________________________________________________ 3.
Valid passport number (for a non-naturalised Vanuatu citizen not issued a Vanuatu passport, please provide a VNPF number, other superannuation number or Vanuatu Driver’s licence number.

Refer to Schedule 1 below): ____________________________________________________________________________ 4.
Have you ever been convicted of any criminal offences in Vanuatu or any other country (particularly offences of dishonesty, fraud, financial crime or offences against legislation relating to banking, financial services, legal person, legal arrangement, and insurance and high value property and fund management)?

If yes, state the details of Court cases, judgements and explain.
____________________________________________________________________________ ____________________________________________________________________________ 5.

Have you ever been convicted of an offence under the AML&CTF Act in Vanuatu or under a similar law in any other country?

If yes, state the details of Court cases, judgements and explain.

____________________________________________________________________________ ____________________________________________________________________________ 6.
Are you or have you been the subject of any proceedings of a disciplinary or criminal nature, or have been notified of any potential proceedings or of any investigation which might lead to those proceedings in Vanuatu or any other country?

If yes, state the details of the occurrences and explain.

____________________________________________________________________________ ____________________________________________________________________________ 7.
Have you ever been dismissed, or asked to resign and resigned, from employment or from a position of trust, fiduciary appointment or similar in Vanuatu or any other country?

If yes, state the details of the occurrences and explain.
____________________________________________________________________________ ____________________________________________________________________________ Corporate Services Service Organisationnel VANUATU GOVERNMENT – Corporate Services La Casa D’Andrea Building, Lini Highway, Private Mail Bag 9012, Port Vila, Vanuatu Telephone: (+678) 33010 Email: CIRCorporate@vanuatu.gov.vu Website: http://customsinlandrevenue.gov.vu 8.
Have you ever been disqualified from acting as a director or disqualified from acting in any managerial position in Vanuatu or any other country?

If yes, state the details of the occurrences and explain.

____________________________________________________________________________ ____________________________________________________________________________ 9.
Have you ever been a director or directly concerned in the management of a reporting entity or any other entity, in Vanuatu or any other country, which has had its licence revoked or has been wound up by the Court?

If yes, state the details of the Court cases, judgements, entities involved, occurrences and explain.

____________________________________________________________________________ ____________________________________________________________________________ 10.
Are you, or the entities you own or manage, currently or about to become bankrupt in Vanuatu or any other country?

If yes, state the details of occurrences, entities involved and explain.

____________________________________________________________________________ ____________________________________________________________________________ 11.
Have you, or the entities you own/owned or manage/managed, ever applied to take the benefit of a law for the relief of bankrupt or insolvent debtors in Vanuatu or any other country?

If yes, state the details of occurrences and explain.

____________________________________________________________________________ ____________________________________________________________________________ 12.

Have you, or the entities you own/owned or manage/managed, ever compounded with creditors?
If yes, state names of entities, the details of occurrences and explain.

____________________________________________________________________________ ____________________________________________________________________________ 13.

Have you been, in the past 10 years, honest and truthful in all your dealings with any regulatory body?

If no, state the details of occurrences and explain.
____________________________________________________________________________ ____________________________________________________________________________ 14.

Are you ready and willing to comply with the requirements and standards of the Department of Customs and Inland Revenue and with other legal, regulatory and professional requirements and standards?

____________________________________________________________________________ 15.
Have you ever contravened any of the requirements and standards of the Department of Customs and Inland Revenue or equivalent standards or requirements of other regulatory authorities, professional bodies, or government bodies or agencies?

If yes, state the details of occurrences and explain.

____________________________________________________________________________ ____________________________________________________________________________ 16.
Do you have actual or potential conflicts of interest that are likely to influence your ability to carry out your role and functions with the appropriate probity and competence in Vanuatu or any other country?

If yes, state and explain.

____________________________________________________________________________ ____________________________________________________________________________ 17.

Do you have adequate experience in the conduct of business duties?
____________________________________________________________________________ Corporate Services Service Organisationnel VANUATU GOVERNMENT – Corporate Services La Casa D’Andrea Building, Lini Highway, Private Mail Bag 9012, Port Vila, Vanuatu Telephone: (+678) 33010 Email: CIRCorporate@vanuatu.gov.vu Website: http://customsinlandrevenue.gov.vu 18.

Do you demonstrate competence and integrity in the conduct of business duties?

____________________________________________________________________________ 19.
Are you of bad repute with the financial and business community in Vanuatu or any other country?

If yes, state the details of occurrences and explain.

____________________________________________________________________________ ____________________________________________________________________________ 20.

Are you listed on any United Nations Financial Sanctions lists, or on any financial sanctions lists as stated under the United Nations Financial Sanctions Act No.
6 of 2017 or any financial sanctions lists under the laws of any jurisdictions?

If yes, state the name/s as you are listed.
____________________________________________________________________________ ____________________________________________________________________________ Signature: _____________________ Date: ___/___/_____ Corporate Services Service Organisationnel VANUATU GOVERNMENT – Corporate Services La Casa D’Andrea Building, Lini Highway, Private Mail Bag 9012, Port Vila, Vanuatu Telephone: (+678) 33010 Email: CIRCorporate@vanuatu.gov.vu Website: http://customsinlandrevenue.gov.vu Schedule 1 – Documents required for you to submit in support of your declaration.
Ni-Vanuatu citizens (Tick [] to indicate where document/s have been provided to the VFIU) Beneficial Owner Board Director Senior Manager  1.

Valid Passport, (non- naturalised ni-Vanuatu citizen without passport may provide VNPF ID card, other superannuation registration, or Vanuatu Driver’s Licence copy) 2.

Vanuatu Police record 3.

Curriculum Vitae 4.
Qualification document/s copy Valid Passport, (non- naturalised ni-Vanuatu citizen without passport may provide VNPF ID card, other superannuation registration, or Vanuatu Driver’s Licence copy) Vanuatu Police record Curriculum Vitae Qualification document/s copy Valid Passport, (non- naturalised ni-Vanuatu citizen without passport may provide VNPF ID card, other superannuation registration, or Vanuatu Driver’s Licence copy) Vanuatu Police record Curriculum Vitae Qualification document/s copy Expatriates and Non-residents (Tick [] to indicate where acceptable copies of document/s have been provided to the VFIU) Beneficial Owner 1.
Valid and certified Passport copy (for non- resident, copy must be certified by registered Justice of Peace/ Commissioner of Oaths/ Notary Public) 2.

Certified Police record of home Country/State (home Country/State is place of issue of passport/ birth place) 3.

Certified Police record of Countries/ States of last employment/ residence for past 10 years (if not the same as above) 4.

Curriculum Vitae (if sole proprietor or performs an executive role) 5.
Qualification document/s copy (if sole proprietor or performs an executive role) Board Director Senior Manager  Valid and certified Passport copy (for non-resident, copy must be certified by registered Justice of Peace/ Commissioner of Oaths/ Notary Public) Certified Police record of home Country/State (home Country/State is place of issue of passport/ birth place) Certified Police record of Countries/ States of last employment/ residence for past 10 years (if not the same as above) Curriculum Vitae Valid and certified Passport copy (for non- resident, copy must be certified by registered Justice of Peace/ Commissioner of Oaths/ Notary Public) Certified Police record of home Country/State (home Country/State is place of issue of passport/ birth place) Certified Police record of Countries/ States of last employment/ residence for past 10 years (if not the same as above) Curriculum Vitae Qualification document/s copy Qualification document/s copy Corporate Services Service Organisationnel