APPLICATION FORMS AND NOTICES (AFN) – AUT - IND2

For DFSA use only

Form AUT – IND 2

Application to extend or vary

Authorised Individual status

Name of individual
Authorised individual number
Name of Authorised Firm
DFSA Reference Number
Firms are requested to contact the supervision department of the DFSA (switchboard +971 (0)4 362 1500 or ) before considering completing an application

Purpose of this form

This form must be submitted by an Authorised Firm applying to extend or vary an Authorised Individual’s authorised status. In some cases the DFSA may require additional information (including the re-submission of a complete form AUT-IND1 (Application for authorisation Authorised Individual Status) in order to complete the processing of this application. If this is necessary, the DFSA will contact the person identified in section 1 of this form.

If the Authorised Individual will cease to perform any Licensed Functions, Form AUT-IND3 (Application to Withdraw Authorised Individual Status) should be submitted instead of this form.

Contents

Section / Title
1 / General information
2 / Changes to Licensed Functions
3 / New or additional Licensed Functions
4 / Fit & proper questionnaire
5 / Additional information
6 / Attachments
7 / Declarations

Notes for completing this form

  • Defined terms are identified throughout this application form by the capitalisation of the initial letter of a word or phrase and are defined in the Glossary module (GLO) of the DFSA’s Rulebook.
  • Unless otherwise specified, applicant refers to the individual for whom Authorised Individual status is being sought.
  • Unless otherwise specified, Authorised Firm refers to the firm on whose behalf the applicant will be carrying out the Licensed Functions and includes, for the purposes of this application, a firm applying for authorisation to carry on Financial Services.
  • Prior to completion of this form Authorised Firms should read the relevant sections of the GEN module of the DFSA Rulebook applying to Authorised Individuals.
  • Sections 1,2,4,6 and 7 must be completed in all cases.
  • Section 3 must be completed when making an application to perform one or more new Licensed Functions.
  • Please use section 5 if you wish to provide additional information to clarify or support your answers in other sections of the form.
  • Questions must be answered fully and the use of abbreviations or acronyms should be avoided or defined.
  • Do not leave any questions blank. If a question is not applicable this should be indicated in the response section. Failure to answer questions or provide full responses will delay the progress of the application.
  • Answers must be typed, in electronic format, and the form must be signed by a Director/Partner of the Authorised Firm. Versions of this form on the DFSA’s website are in PDF format. Editable Microsoft Word versions can be obtained from the DFSA.

SECTION 1 - GENERAL INFORMATION

About the applicant

1.1 / Authorised Individual number (AIN)
1.2 / Title (Mr, Mrs etc.)
1.3 / Family name
1.4 / Other names
1.5 / Residential address

About the Authorised Firm

1.6 / Name of Authorised Firm
1.7 / DFSA Licence number
1.8 / Applicant’s contact person for this application
1.9 / Contact telephone number
1.10 / Contact fax number
1.11 / Contact e-mail

SECTION 2 - CHANGES TO LICENSED FUNCTIONS

2.1 / Please indicate any changes to the applicants Licensed Functions
Add* / Withdraw
2.1.1 / Senior Executive Officer
2.1.2 / Licensed Director
2.1.3 / Licensed Partner
2.1.4 / Finance Officer
2.1.5 / Compliance Officer
2.1.6 / Senior Manager
2.1.7 / Money Laundering Reporting Officer
2.1.8 / Responsible Officer

* For additions please complete section 3.

SECTION 3 - NEW OR ADDITIONAL LICENSED FUNCTIONS

3.1 / Current job title
3.2 / Proposed job title (if different)
3.3 / Proposed commencement date of new Licensed Function(s)
3.4 / Please detail below or attach the revised job description of the applicant clearly outlining the additional responsibilities to be performed as a result of this application. Please indicate how much of the applicant’s time will be allocated to the performance of these additional responsibilities.
3.5 / Please describe in detail how the Authorised Firm has determined that the applicant is competent to carry out the additional Licensed Function(s).
Technical competence
(Please include the relevant qualifications and training specific to the proposed Licensed Function on which you have determined the candidate’s competence for the Licensed Functions to be carried out)
Relevant experience
(Please include the relevant experience specific to the proposed Licensed Function on which you have determined the candidate’s competence for the Licensed Functions to be carried out)

SECTION 4 - FIT & PROPER QUESTIONNAIRE

4.1 / Please complete the following questionnaire in relation to the applicant
Answers must be provided to every question.
Has the applicant: / Yes / No
(i) / been convicted or found guilty by any court of competent jurisdiction in respect of any offence, other than a minor road traffic offence?
(ii) / ever been the subject of disciplinary procedures by a government body or agency or any self regulatory organisation or other professional body?
(iii) / contravened any provision of Financial Services legislation or of Rules, Regulations, statements or Principles or codes of practice made under or by a Financial Services Regulator or other supervisory body?
(iv) / been refused or restricted the right to carry on a trade, business or profession requiring a Licence, registration or other authority?
(v) / been dismissed or requested to resign from any office of employment?
(vi) / been concerned with the management of a Body Corporate which has been or is currently the subject of an investigation into a allegation of misconduct or malpractice?
(vii) / received an adverse finding in a civil action by any court of competent jurisdiction of fraud misfeasance, or other misconduct, whether in connection with the formation or management of a corporation or otherwise?
(viii) / received an adverse finding in an agreed settlement in a civil action by any court or tribunal of competent jurisdiction resulting in an award against an Individual in excess of $10,000 or awards that total more than $10,000?
(ix) / been the subject of an order of disqualification as a Director or otherwise to act in the management or conduct of the affairs of a corporation by a Court of competent jurisdiction or regulator?
(x) / been a Director, or Partner or concerned in the management of a company or Partnership which has gone into insolvent liquidation whilst the individual was connected with that company, Partnership or within one year of such a connection?
(xi) / been the subject of complaint in connection with a Financial Service or Ancillary Service which relates to his integrity, competence or financial soundness?
(xii) / been censured, disciplined, publicly criticised by or the subject of a court order at the instigation of a Financial Services Regulator or any officially appointed inquiry?

If you have answered Yes to any questions, please provide appropriate details of the matter below

SECTION 5 - ADDITIONAL INFORMATION

Please use this section to provide any additional information that may clarify or support your answers in any other sections of the form.

Question / Details

SECTION 6 - ATTACHMENTS

Relevant
Question / Attachment Required / Attachment Included
Yes / To Follow / N/A
3.4 / Revised job description
Other / Please list

SECTION 7 - DECLARATIONS

Declaration by the applicant

  1. I declare that, to the best of my knowledge and belief, having made due enquiry, the information given in this form is complete and correct. I understand that it is an offence under Article 66 of the Regulatory Law 2004 to provide to the DFSA any information which is false, misleading or deceptive or to conceal information where the concealment of such information is likely to mislead or deceive the DFSA.
  1. I declare that, I am fit and proper to perform the Licensed Functions to which this application relates and, in the event of a failure on my part to remain fit and proper, I shall notify the DFSA of such fact as reasonably practical.
  1. I declare my understanding that the DFSA may request more detailed information (including but not limited to, personal, educational, employment and financial information) should it be deemed necessary to assess my fitness and propriety adequately. I consent to the DFSA contacting any previous employers, educational institutions, professional organisations or any other organisation, to verify any information contained in this form.

4.For the purposes of complying with DIFC Data Protection Law 2007, I understand that any Personal Data provided to the DFSA will be used to discharge its regulatory functions under the Regulatory Law 2004 and other relevant legislation and may be disclosed to third parties for those purposes.

Signature of applicant / Date
Name of applicant

Declaration by the Authorised Firm

  1. I declare that, the applicant’s competence has been assessed in accordance with the requirements of the DFSA Rulebook and I declare that the applicant is competent to perform the Licensed Functions to which this application relates.
  1. I declare that, to the best of my knowledge and belief, having made due enquiry into the applicant’s background and qualifications, the information given in this form is complete and correct. I understand that it is an offence under Article 66 of the Regulatory Law 2004 to provide to the DFSA any information which is false, misleading or deceptive or to conceal information where the concealment of such information is likely to mislead or deceive the DFSA.
  1. I declare that to the best of my knowledge and belief, having made due enquiry, the applicant is fit and proper to perform Licensed Functions to which this application relates.
  1. I confirm that I have the authority to make this application, to declare as specified above and sign this form for, or on behalf of, the Authorised Firm.

Signature of Senior Executive Officer or Compliance Officer / Date
Name of Senior Executive Officer or Compliance Officer

Please return the completed form to:

Dubai Financial Services Authority

Authorisation Department

Level 13, The Gate

PO Box 75850

Dubai, UAE

Firms are advised to retain a copy of the form and all relevant attachments for their records.

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