IN CONFIDENCE

QUESTIONNAIRE IN CONNECTION WITH

THE RESIDENCE PROGRAMME

ThisquestionnairehasbeenpreparedinconnectionwithThe Residence Programme application.Itis animportantdocumentandyoushouldthereforeanswerallquestionstruthfully andwithoutomission. Any failure to discloserelevantandmaterialinformationmay resultinyourapplicationbeingterminated.

Instructions

Please type all responses.

Please answer all questions. If a question is answerable in the negative, please respond “No”. If a question is not applicable, please answer “N/A”. Do not leave any section blank.

If insufficient space is provided for completion of any question, additional information may be entered at Annex A, duly signed and attached.

In this form, the term “company” is taken to include any company or corporate/commercial entity, wherever incorporated/registered (to include partnerships, sole traderships and such like). “Director” means a person in accordance with whose directions or instructions the company’s directors are or were accustomed to act.

Please attach the following documentation:

  • a full, recent curriculum vitae (which should provide a clear account of your career)
  • a certified copy of the photographic page of your passport
  • a certified copy of of a full driving licence or other official document bearing your residential name and current address
  • certified copies of two recent (preceding three months) utility bills for your principal residential address (a mobile phone bill is not sufficient)
  • a statement of good standing from your principal personal bank (i.e. the bank through which you coordinate the majority of your domestic financial affairs)

N.B. Certified copies should include the following details with respect to the certifier: name, occupation, address, telephone number, length of time known to person and in what capacity.

1.
a) / Full name and surname
(if your native language does not use Latin script [Arabic, Chinese, Cyrillic, etc.], please also write in native language)
b) / Other names/aliases/previous names
c) / Date and place of birth
d) / Parents’ names and dates of birth
e) / Nationality (and, if applicable, previous nationalities)
f) / Passport number
g) / National ID number (if applicable)
h) / Other citizenships (if applicable)
j) / Principal residential address
(please also write in native language, where appropriate)
k) / Other Residential addresses
l) / Marital status (single, married/civil partner, unmarried partner, divorced, separated, widowed etc.)
m) / Name of spouse/civil partner, if applicable (please also write in native language, if applicable).
n) / Email address(es) (work & private)
p) / Telephone contact details (mobile/cell, fixed line etc.)
2
a) / Current work status
(employee, self-employed, retired, unemployed etc.)
b) / Current employer and/or details of self-employment (please write in native language, if applicable)
c) / Employer’s/Business address
(please write in native language, if applicable)
3. Please provide a summary of the economic activity that led to the creation of your wealth/economic well-being. (This should be more than just a sentence and should build, in a descriptive way, upon the more specific information in your CV.)
4 Have you ever been either a public sector employee in any country (i.e. armed forces, security services and law-enforcement, government/civil servant, judiciary etc.) or political figure/appointee?
If “yes”, please provide further details, including the name of the organisation, your title, and dates of employment/association.
5.Are you, or have you in the last 15 years been: a director shadow director or occupied any managerial position of any other company or a partner in any partnership? If so, please use Annex A to provide the required information.
6. Have you ever been suspended, dismissed or requested to resign from any office or employment, or removed from any fiduciary office or position of trust, whether or not remunerated?
7. Has any company of which you have been a director been put into compulsory or voluntary liquidation, had a company voluntary arrangement or arrangement with its creditors generally, or an administrator or an administrative or other receiver appointed during the period when you were (or within the preceding twenty-four months after you had been) one of its directors or shadow directors?
Has any partnership been put into compulsory or voluntary liquidation or been sequestrated during the period when you were (or within the preceding twenty-four months had been) one of its partners?
If so, in each case state the name, nature of business, date of commencement of winding up, administration or receivership and the amount involved, together with an indication of the outcome or current position.
8. Have you at any time, or has a company of which you were a director or shadow director at the time of the offence, been convicted of any offence involving fraud or dishonesty or an offence under legislation relating to companies (including insider dealing), building societies, industrial and provident societies, credit unions, friendly societies, insurance, banking or other financial services, securities, insolvency, consumer credit or consumer protection?
If so, state the court by which you were or the company was convicted, the date of conviction and full particulars of the offence and the penalty imposed.
Details must be disclosed of all convictions of the kind described above even where they may be “spent convictions”.
9. Have you been concerned with the management or conduct or affairs of any company or partnership that has been investigated by any government or regulatory body in relation to any matter that was ongoing when you were associated with that company or partnership?
10. Have you, in connection with the formation or management of any company, partnership or unincorporated institution been adjudged by a court civilly and/or criminally liable for any fraud, misfeasance or other misconduct by you towards it or towards any of its members? If so, give full particulars.
11. Have you ever been disqualified by a court from acting as a director of a company, or from acting in the management or conduct of the affairs of any company? If so, give full particulars.
12. Have you personally, or any business, company or firm of which you have been a director (or concerned with the management of the business, company or firm) been the subject of adverse media comment?
13. Have you ever been publicly censured or disciplined in relation to your business or professional activities?
14. Further to question 8, have you ever been charged or convicted of any offence (including spent convictions but not motor convictions)? If so, state the court by which you were convicted, the date of conviction and full particulars of theoffence and the penalty imposed.
15. Have you ever, in either a personal or commercial capacity, been the subject of any investigation by law enforcement, security & intelligence, regulatory and tax authorities.Furthermore, please also state whether you are aware of any circumstances that may to lead to such an investigation.
16. In the last 10 years, have you been the subject of a claim for unpaid taxes or been involved in any investigation, litigation or arbitration; or are aware of any circumstances which are likely to lead to any involvement in the above.
17. Have you at any time been adjudged bankrupt?If so, state the court by which you were adjudged bankrupt and, if discharged, the date and conditions on which you were granted your discharge.
18. Have you at any time been a party to a deed of arrangement or any form of voluntary financial debt restructuring arrangement with creditors? If so, give full particulars.
19. Are there any unsatisfied judgments outstanding against you? If so, give full particulars.
20. Have you ever been refused admission, or renewal of, membership of any professional body, trade, society or investment exchange, or been censured or disciplined or had membership withdrawn by any such body to which you belong or belonged? If so, give full particulars.
21. In relation to the questions above, would any additional disclosure be required in relation to any of your dependants andhousehold staff as defined in Rule 2 of The Residence Programme Rules (LN 270 of 2014)? If yes, please provide full details.
22. Is there any other information material that is not disclosed above that may be material to the assessment of your suitability? If so, give full particulars.

DECLARATION

I declare that the information supplied above is true, complete and not misleading in any way. If any of the information supplied changes or needs to be supplemented after the date of this Declaration (and prior to my application being approved), I undertake to inform the Commissioner for Revenue immediately and to update my Declaration accordingly.

I authorise the Commissioner for Revenue or any of its employees or authorised representatives to perform independent verification of the information that I have given, to make those enquiries about me as it may consider necessary and to disclose the contents of this declaration to those advisers it deems such disclosure necessary.

Signature:______

Name in Full: ______

Date:______

Annex A

Additional Information

Ref. / Comment

Sep 14 (v1) 1

IN CONFIDENCE

Annex B

Company Appointments

No. / Company Number / Company Name / Country of Incorp. / Date of Incorp. / Business Activity / Dates of Service/Appointment / URL
(website) / Comments

Sep 14 (v1) 1