Forindividualwho Has Completed Part 4Of This Form
Please tick (×) where applicable
Class A licence: To carry on money changing and remittance business
Class B licence: To carry on remittance business only
Class C licence: To carry on money changing business only
Class D licence: To carry on wholesale currency business only
Part 2: Applicant’s particulars
(a) / Background
Name of company / Telephone no.
BRIC no. / Fax no.
Date of incorporation / Email address
Name of contact person
Business address
Business registered address
(if address belongs to company secretary of the applicant, please state the name, telephone and fax number of secretary company) / Document to be enclosed:
Please tick (×) if enclosed together with the form
- Certified true copy of Form 9 issued by Companies Commission of Malaysia
- Certified true copy of the company’s M&A
(b) / Proposed shareholders and shareholding structure
If space provided is insufficient , please provide in a separate sheet
Name
(may be an individual or company) / NRIC/passport/BRIC number / Nationality / Amount of shareholding (RM) / Percentage of shareholding
1.
2.
3.
4.
5.
Total /
(c) / Proposed Board of Directors, Chief Executive Officer (CEO) or key responsible person for day-today management of the company
If space provided is insufficient , please provide in separate sheet
Name / NRIC/passport number / Nationality / Designation/resposibility
e.g. Non-executive director, Managing director, CEO, Manager etc
1.
2.
3.
4.
5.
(d) / Corporate structure
Applicable if applicant is part of group of companies
Please furnish the corporate structure of applicant i.e. parent/sister company and explain in brief of business activities of each related companies in separate sheet of paper
(e) / Business plan
Please furnish business plan on separate sheet of paper. Business plan of applicant should contain, among others:
1.Proposedlocation of business (full address is not required);
2.Feasibility studies on business model, potential customer, projected growth and income for the next three years including cash flow, source of funds for business operation; and
3.Proposed governance arrangements, internal controls and risk management framework to manage the business operations.
Please refer to Money Services Business (Licensing) Regulation 2012 for further information (available at the Bank’s website)
Part 3: Declaration on the information provided and consent for disclosure of information
1.The company confirms that all the information given in this document and the documents submitted are true, and understands that if the company furnishes any information required which is false, inaccurate, misleading or contains material errors or omissions, the licence may not be granted by Bank Negara Malaysia (Bank). In the event that the licence has been granted, it may be revoked;
2.The company applies for a licence to carry on Money Services Business under section 5 of the Money Services Business Act 2011 based on information provided with this application and any additional information provided to the Bank in the course of the application; and
3.The company will promptly notify the Bank in writing of any changes in the information the company has provided and supply any other relevant information which may come to light in the period during which its application is being considered by the Bank. The companyacknowledges that the Bank may disclose any information provided in the performance of its statutory functions or otherwise as may be specifically authorised by law.
I, as a person who is authorised signatory of ______(name of company) and responsible for the management of the company:
(a)Make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Statutory Declarations Act 1960; and
(b)As provided under item(1) of Schedule 11 made in pursuant to section 134 of the Financial Services Act 2013 (FSA), item (1) of Schedule 11 made in pursuant to section 146 of the Islamic Financial Services Act 2013 (IFSA) and section 120(1)(c) of the Development Financial Institutions Act 2002 (DFIA),I hereby authorize any licensed business under FSA and IFSA and prescribed institutions under DFIAwhere the applicant maintains its accounts, or has financial liabilities, to disclose to Bank NegaraMalaysia, any information relating to the company’s accounts and affairs including financial liabilities for the purpose of processing this application.
______
(Date) (Signature) (Name in capital letter) (Designation)
This declaration was made before me:
______
(Signature of Session Court Judge, Magistrate or Commissioner For Oaths)
Date:
Note:
Please do not enclose any payment for licence fee with the application. Licence fee is payable upon the approval of application. Applicant will be informed in writing of the Bank’s decision on the application.
Part 4: Form to be completed by each director/shareholder/CEO/or key responsible person of the company applying for the money services business licence
(Please make copies of Part 4 for each individual)
(a) / Designation of key responsible person
Please tick (×) where applicable. Tick more than one box if you hold more than one position / Please attach latest passport sized
photograph here
Director
Shareholder
Chief Executive Officer*
* Or whatever name i.e. general manager/manager who is responsible for the conduct of business and the day-to-day management
(b) / Particulars
If the shareholder is a company/corporation, please complete relevant items in Part 4(b)
Name / Document to be enclosed:
Please tick (×) if enclosed together with the form
- For individual - Certified true copy of NRIC/passport and insolvency report (local/foreign)
- For company:
-Certified true copy of the company’s memorandum and association
Gender(not applicable for a company)
NRIC/Passport/BRIC no.
(whichever applicable)
Nationality (not applicable for a company)
Current address
(for company, please state the name of contact person)
Telephone no. (home/office) / Fax no.
Telephone no. (mobile) / Email address
(c) / Working experience (for the last 5 years)
(for individual)
Position/designation / Organisation/company / Business activity / Duration of service
(year to year)
1.
2.
3.
4.
5.
(d) / Educational background
(for individual)
Highest level / Institution / Year obtained /
1.
2.
3.
4.
5.
(e) / Details of other business owned or interest owned in other business (including money services business) (please provide additional sheet if space provided is inadequate)
Name of business / Business activity / Type of interest
(e.g. shareholder, director, partner etc) / Amount and percentage of shareholding owned in other business
1.
2.
3.
4.
5.
(f) / Are any of your family members (parents, siblings, spouse and children) having interest in any money services business? If yes, please fill the following
Name of family member / Relationship with you / Name of money services business / Type of interest
(e.g. shareholder, director, partner etc)
1.
2.
3.
4.
5.
(g) / Statutory Declaration
I, ______(name of applicant), of NRIC / Passport No. ______do solemnly and sincerely declare that:
A:I am not subject to the disqualifications mentioned below:
(i) I have not been convicted of an offence under the repealed Money Changing Act 1998 [Act 577], the Money Services Business Act 2011 [Act 731], the repealed Payment Systems Act 2003 [Act 627], the repealed Banking and Financial Institutions Act 1989 [Act 372], the repealed Insurance Act 1996 [Act 553], the repealed Islamic Banking Act 1983 [Act 276], the repealed Takaful Act 1984 [Act 312], the repealed Exchange Control Act 1953 [Act 17], the Financial Services Act 2013 [Act 758], the Islamic Financial Services Act 2013 [Act 759], the Central Bank of Malaysia Act 2009 [Act 701], the Development Financial Institutions Act 2002 [Act 618], the Anti-Money Laundering and Anti-Terrorism Financing Act 2001 [Act 613], the Capital Markets and Services Act 2007 [Act671] or the Companies Act 1965 [Act 125];
(ii) I have not been convicted of a criminal offence relating to dishonesty or fraud under any written law within or outside Malaysia;
(iii) If I have been convicted of a criminal offence not relating to dishonesty or fraud under any written law within or outside Malaysia, a period of five years has lapsed since the completion of my sentence*;
(iv) I am not an undischarged bankrupt;
(v) I have not suspended payments or compounded with my creditor whether in or outside Malaysia;
(vi) (a) I have not been issued with an order of detention, supervision, restricted residence, banishment or deportation; or
(b) I have not been imposed with any form of restriction or supervision by bond or otherwise,
under any law relating to prevention of crime, preventive detention for prevention of crime or drug trafficking, restricted residence, banishment or immigration;
(vii) I have not held the position of a director or been directly concerned in the management of any company which has been convicted of an offence under any written law designed to protect members of the public against financial loss due to dishonesty, incompetence or malpractice during the tenure of my office;
(viii) I am a person of probity, personal integrity and good reputation;
(ix) I possess the appropriate skills, experience and have sufficient knowledge of the Money Services Business Act 2011 and the relevant provisions in the Anti-Money Laundering and Terrorism Financing Act 2001 to effectively fulfil the role and responsibilities of the position;
(x) I have managed my affairs properly and prudently; and
(xi) If I am to be appointed as a chief executive officer or to be primarily responsible for the day-to-day management of the company, I will be available for full time employment.
B:I am*:
(i)representing the interest of ______; or
(ii)not representing the interests of any person;
C:All the information submitted above is true.
This declaration was made before me:
(Signature of Sessions Court Judge, Magistrate or Commissioner For Oaths)
Date:
Part 5: Consent for Disclosure of Information
Please complete where applicable:
- Forindividualwho has completed Part 4of this form.
______
(Date) (Signature) (Name in capital letter) (Designation)
- For a company(corporate shareholder) which has completed Part 4 of this form.
[Consent should be given by the director/CEO who is responsible of the management of the company].
______
(Date) (Signature) (Name in capital letter) (Designation)
IMPORTANT:
BANK NEGARA MALAYSIA MAY REQUEST FOR ADDITIONAL INFORMATION AS AND WHEN REQUIRED
Delete whichever not applicable/relevant