Appointed Representative & Company Representative Application Form

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Appointed Representative & Company

Representative Application Form

FIRM DETAILS

Full name of business and any trading styles

Type of business Partnership Limited Company

Limited Liability Partnership Sole Trader Other (Please specify)

Number of years trading

(If a new firm, please give your experience and rationale for starting the firm. Please use additional info section.)

Contact address

Contact name Telephone number Fax number Email address Website address

Companies House details (If applicable, e.g. for limited companies and limited liability partnerships only) Date of incorporation

County of incorporation Registration number FCA firm reference number

Ingard, Ryan House, 18-19 Aviation Way, Southend on Sea, Essex SS2 6UN

Telephone: 0845 371 3433 | Website: www.ingard.co.uk 01

IMPORTANT CHECKLIST:

In addition to your fully completed application form, please can you tick the boxes below to indicate that you have: Enclosed a copy of your FCA Consumer Credit Permissions

Enclosed a copy of your Data Protection Registration (DPA) Enclosed copies of Qualification Certificates for Advisers Completed the appropriate attached Direct Debit Instruction

Enclosed a copy of a credit report for each individual (www.uk.experian.com) Enclosed certified proof of ID and proof of address for each Individual/Controller

For office use only: BDM/Introducing source Payment Terms

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Please list below ALL controllers and directors of the firm. Somebody that owns 10% or greater of the company are automatically controllers, including Company Secretary.

Full name Job Title

% of share holding (if applicable)

Full name Job Title

Has the applicant firm ever held any licence or authorisation at any time under: (IF YES, PLEASE PROVIDE DETAILS IN THE ADDITIONAL INFO SECTION).

The Prevention of Fraud (Investments) Act 1958 or the Prevention of Fraud (Investments) Act (Northern Ireland) 1940? Yes No

The Consumer Credit Act of 1974? Yes No

The Insurance Brokers (Registration) Act 1977? Yes No

Has the applicant firm ever been a member of, authorised or registered by the Financial Conduct Authority (FCA), any Recognised Self-Regulating Organisation, any voluntary regulator or any Recognised Professional Body

(currently or previously)? (Please provide full information in the additional information section). Yes No

Has the applicant firm ever had: Any licence held under the Statutes? Yes No

Membership of any association of dealers in securities, any stock exchange or other professional body? Yes No Membership or any Authorisation to carry out insurance, investment or banking business, refused,

revoked or withdrawn? Yes No

Has the applicant firm ever resigned from or discontinued an application for membership or authorisation to

any of the bodies mentioned? Yes No

(Although the information requested relates to UK provisions, details of comparable overseas provisions should also be supplied).

Disciplinary proceedings

Has the applicant firm ever been the subject of, or interviewed in the course of, any existing or previous investigation or disciplinary proceedings, by the FCA, by other regulatory authorities (including a previous regulator), clearing

house and exchanges, professional bodies or government agencies? Yes No

Is the applicant firm currently the subject of any disciplinary proceedings or is it aware that such proceedings

are pending? Yes No

Has the applicant firm ever been the subject of a formal investigation under the powers set out in:

The Insurance Companies Act1982? Yes No

The Companies Act1985? Yes No

The Financial Services Act1986? Yes No

The Financial Services & Markets Act 2000? Yes No

Ingard, Ryan House, 18-19 Aviation Way, Southend on Sea, Essex SS2 6UN

Telephone: 0845 371 3433 | Website: www.ingard.co.uk 02

Where a reference to an act of parliament or any regulatory body this includes anything that supersedes, replaces or is in addition to.

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Criminal or civil proceedings

Has the applicant firm ever been a defendant in any civil proceedings, or party to any arbitration, in relation to any investment business or other financial business (i.e. mortgage related matters) or been charged or convicted

under the Theft Act or been the subject of any other criminal proceedings? Yes No Judgments & debts - has the firm ever:

Had a petition presented or a meeting summons to consider a resolution, to wind up the organisation or has the

organisation wound up? Yes No

Had its estate sequestered, or is the organisation currently the subject of proceedings or are you aware of any

proceedings for the sequestration of its estate? Yes No

Had a receiver, administrative receiver or administrator appointed in respect of the whole or any part of its property? Yes No Had an administrator, receiver, or trustee appointed or an application made for such an appointment? Yes No Made a composition or arrangement with one or more of its creditors, or made proposals for such? Yes No Ceased trading in circumstances in which any of its creditors did not receive full payment? Yes No

Had any judgment debt entered against it? Yes No

Been struck off the register by the Registrar of Companies? Yes No

Been convicted by a court (whether magistrates,crown or military) for any offence? Yes No Been subject to penalties for tax evasion or an investigation conducted by the tax authorities? Yes No Been adjudged by a court liable for any fraud,wrongful trading or other misconduct? Yes No Had any associated business (whether or not connected with the Financial Services Industry) Yes No If yes please give details in the space provided.

Will any of these businesses conflict with your Financial Services Business? Yes No If yes please give details in the space provided.

Been or previously been, authorised under the Financial Services & Markets Act 2000? Yes No If yes please give details in the space provided.

03 PERSONAL DETAILS

(This section must be completed by ALL controllers and advisers)

APPLICANT 1 APPLICANT 2 APPLICANT 3 APPLICANT 4

Title Surname Forename Middle Name(s) Date of birth Place of birth NI Number Home Address

Daytime tel no Daytime fax no Email address

If less than 3 years at this address please provide full address history for the last 3 years in additional information section on pages 9 and 10. This is a mandatory requirement.

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PERMISSIONS REQUIRED

Please indicate which permissions you require:

Mortgages (Standard) Mortgages (Standard) Mortgages (Standard) Mortgages (Standard) Mortgages (Equity Release) Mortgages (Equity Release) Mortgages (Equity Release) Mortgages (Equity Release) Non-Investment Insurance Non-Investment Insurance Non-Investment Insurance Non-Investment Insurance

Please give details of experience in each area you are applying for (in years):

Please confirm the total number of cases written over the last 12 months:

QUALIFICATIONS

Please indicate your qualifications as below (please enclose certified copies of certificates):

FPC Part 1 FPC Part 1 FPC Part 1 FPC Part 1

Full Full Full Full

FPC + bridge paper FPC + bridge paper FPC + bridge paper FPC + bridge paper

CeMap Part 1 CeMap Part 1 CeMap Part 1 CeMap Part 1

CeFA 1 CeFA 1 CeFA 1 CeFA 1

CF1 CF1 CF1 CF1

CF2 CF2 CF2 CF2

CF3 CF3 CF3 CF3

CF4 CF4 CF4 CF4

CF5 CF5 CF5 CF5

CF6 CF6 CF6 CF6

Other (please state) Other (please state) Other (please state) Other (please state)

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FITNESS & PROPRIETY

This section must be completed by ALL individuals.

(IF YOU ANSWER YES TO ANY OF THESE, PLEASE PROVIDE ADDITIONAL INFORMATION AT THE END OF THIS FORM)

APPLICANT 1 APPLICANT 2 APPLICANT 3 APPLICANT 4 Have you,or a firm that you have been associated with had a lender or insurer agency withdrawn or terminated?

Yes No Yes No Yes No Yes No

Have you ever had any convictions in respect of any criminal offence of dishonesty, fraud financial crime or violence?

Have you ever had any convictions in respect of any offence under legislation relating to:

Banking Yes No Yes No Yes No Yes No

Financial Services Yes No Yes No Yes No Yes No

Companies Yes No Yes No Yes No Yes No

Insurance Yes No Yes No Yes No Yes No

Are you currently subject to any criminal charges in respect of any criminal offence of dishonesty, fraud, financial crime or violence?

Are you currently subject to any charges, civil proceedings or litigation in respect of offences under legislation relating to:

Banking Yes No Yes No Yes No Yes No

Financial Services Yes No Yes No Yes No Yes No

Companies Yes No Yes No Yes No Yes No

Insurance Yes No Yes No Yes No Yes No

Are there currently any outstanding judgement debts or awards (whether in full or in part) against you?

Have you ever been the subject of a bankruptcy petition, county court judgement, an insolvency petition, an application to dissolve, the appointment of a receiver, administrator or trustee or entered into a composition or agreement with creditors?

Have you ever defaulted on a mortgage, loan or other credit agreement?

Have you previously held a senior position in a firm that: Has been rejected for registration with the FCA or any other

regulator? Yes No Yes No Yes No Yes No

Had sanctions imposed by an FCA disciplinary committee or any other regulator?

Is currently subject to disciplinary procedures? Yes No Yes No Yes No Yes No Has voluntarily deregistered from the FCA or any other regulator, or allowed their registration to lapse?

Have you, or any firm of which you have been a director, partner or controller, in the last three years been the subject of any:

Bankruptcy Yes No Yes No Yes No Yes No

Insolvency Yes No Yes No Yes No Yes No

Liquidation proceedings Yes No Yes No Yes No Yes No

Please provide details of all existing authorisations or approvals held by you in the financial services sector:

Ingard, Ryan House, 18-19 Aviation Way, Southend on Sea, Essex SS2 6UN

Telephone: 0845 371 3433 | Website: www.ingard.co.uk 05

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APPLICANT 1 APPLICANT 2 APPLICANT 3 APPLICANT 4 Have you ever had the right to conduct any trade, business or profession for which a specific licence, authorisation, registration, membership or permission is required, and had it:

Refused Yes No Yes No Yes No Yes No

Restricted Yes No Yes No Yes No Yes No

Terminated Yes No Yes No Yes No Yes No

Have you ever been or are you currently the subject of any disciplinary investigation by a regulator or government body or agency?

In the past 5 years, have you been a director, partner or controller of any financial services sector business that has:

Ceased to trade Yes No Yes No Yes No Yes No

Become insolvent Yes No Yes No Yes No Yes No

Gone into liquidation Yes No Yes No Yes No Yes No

Had an administrator appointed Yes No Yes No Yes No Yes No

If YES to any of the above questions, please include a seperate sheet with a full explanation and any supporting documentation. Have you received any complaints in the last 5 years? Yes No Yes No Yes No Yes No Please state how many were upheld providing details of compensation paid and supporting documentation where necessary.

Ingard, Ryan House, 18-19 Aviation Way, Southend on Sea, Essex SS2 6UN

Telephone: 0845 371 3433 | Website: www.ingard.co.uk 06

EMPLOYMENT DETAILS

Please provide employment details to cover the last 10 years. If there are more than 4 individuals within your firm, or you need additional space, please photocopy this page.

Current Employment

Job Title

Start date of employment

What is your employment status?

Employed Employed Employed Employed

Self-employed Self-employed Self-employed Self-employed

Unemployed Unemployed Unemployed Unemployed

Full Time Education Full Time Education Full Time Education Full Time Education

What is your job role:

Director/Controller Director/Controller Director/Controller Director/Controller

Mortgage/Insurance Advisor Mortgage/Insurance Advisor Mortgage/Insurance Advisor Mortgage/Insurance Advisor

If you are currently an Appointed Representative of an FCA authorised firm, please state: Name of current firm

FCA firm reference number (FRN) (if applicable)

Address of current employer

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APPLICANT 1 APPLICANT 2 APPLICANT 3 APPLICANT 4 Are you a member of a Network?

If ‘yes’ please state name of Network

If you have previously been approved by the FCA, please state your FCA Individual Reference Number

DO YOU CONSENT TO APPROACHING THIS EMPLOYER?

Previous Employment Start date of employment

End date of employment

Job Title

Were/are you?

Full Time Education Full Time Education Full Time Education Full Time Education Name of firm

Was the firm FCA Authorised or a member of a network?

Yes No Yes No

Yes No Yes No If ‘yes’ state network/FCA No.

Nature of business

Address

Postcode

Is/Was the firm regulated by a body?

If ‘yes’ state name of body

Reason for leaving

Ingard, Ryan House, 18-19 Aviation Way, Southend on Sea, Essex SS2 6UN

Telephone: 0845 371 3433 | Website: www.ingard.co.uk 07

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APPLICANT 1 APPLICANT 2 APPLICANT 3 APPLICANT 4 Start date of employment

End date of employment

Job Title

Were/are you?

Full Time Education Full Time Education Full Time Education Full Time Education Name of firm

Was the firm FCA Authorised or a member of a network?

Yes No Yes No

Yes No Yes No If ‘yes’ state network/FCA No.

Nature of business

Address

Postcode

Is/Was the firm regulated by a body?

If ‘yes’ state name of body

Reason for leaving

08 Ingard, Ryan House, 18-19 Aviation Way, Southend on Sea, Essex SS2 6UN

Telephone: 0845 371 3433 | Website: www.ingard.co.uk

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09 PROFESSIONAL/CHARACTER REFERENCES

Please provide a name & address of one professional referee. This should be an individual who has known you within a professional capacity for at least the last 5 years. Specifically they should have experience of your conduct of business through business dealings with you in a professional capacity (eg. accountant, solicitor, colleague within the same industry who has had professional dealings with you). Please note that this individual should be able to verify your employment history and supply details should there be a gap of more than 3 months in your employment.

Title Surname Forename(s) Name of Business

Occupation/Qualification

Business Address

Telephone No Email address

ADDITIONAL INFORMATION

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MORTGAGES│INSURANCE│COMMERCIAL│BRIDGING│EQUITY RELEASE│LOANS

Authorised and Regulated by the Financial Conduct Authority 450731. This is intended for use by Financial Intermediaries only and not the General Public. Ingard is a trading style of Ingard Financial Ltd. Registered in England & Wales.

Registered No. 5728066. Registered Office: 1 Nelson Street, Southend on Sea, Essex SS1 1EG.

Appointed Representative & Company Representative Application Form