Part One: Form of Template
Guide to using this template: Each question must be answered. Where there is nothing to disclose, this should be confirmed by ticking the “No” box for the relevant question. In this template: • “we” / “our firm” refers to the firm or firms giving the reference (as set out in either 1A or 1B below); • “individual” refers to the subject of the reference (as set out in 2 below); and • “your” refers to the firm requesting the reference (as set out in 3 below). |
| Information requested | Response | |
|---|---|---|
| 1A | Name, contact details and firm reference number of firm providing reference; or | |
| 1B | Names, contact details and firm reference numbers (where applicable) of group firms providing a joint reference | |
| 2 | Individual’s name (i.e. the subject of the reference) | |
| 3 | Name, contact details and firm reference number of firm requesting the reference | |
| 4 | Date of request for reference | |
| 5 | Date of reference | |
| The answers to Questions A to F cover the period beginning six years before the date of your request for a reference and ending on the date of this reference | |||
|---|---|---|---|
| Question A | |||
| Has the individual: | |||
| (1) performed a certification function for our firm; or | |||
| (2) been an approved person for our firm. | |||
| Answer: | |||
| Yes | |||
| No | |||
| Question B: | |||
| Has the individual performed one or more of the following roles in relation to our firm: | |||
| (1) notified non-executive director; | |||
| (2) credit union non-executive director; | |||
| (3) key function holder (other than a controlled function); or | |||
| (4) board director. | |||
| Answer: | |||
| Yes | |||
| No | |||
| Question C: | |||
| If we have answered ‘yes’ to either Question A or B above, we set out the details of each position held below, including: | |||
| (1) what the controlled function, certification function or key function holder role is or was; | |||
| (2) (in the case of a controlled function) whether the approval is or was subject to a condition, suspension, limitation, restriction or time limit; | |||
| (3) whether any potential FCA governing function is or was included in a PRA controlled function; and | |||
| (4) the dates during which the individual held the position. | |||
| Answer: | |||
| Question D: | |||
| Has the individual performed a role for our firm other than the roles referred to in Questions A and B above: | |||
| Answer: | |||
| Yes | |||
| No | |||
| If ‘yes’, we have provided summary details of the other role(s), e.g. job title, department and business unit, below. | |||
| Question E: | |||
| Have we concluded that the individual was not fit and proper to perform a function: | |||
| Answer: | |||
| Yes | |||
| No | |||
If ‘yes’ and associated disciplinary action was taken as a result, please refer to Question F below. If ‘yes’, and no associated disciplinary action was taken as a result, we have set out below the facts which led to our conclusion. | |||
| Question F: | |||
| We have taken disciplinary action against the individual that: | |||
| (1) relates to an action, failure to act, or circumstances, that amounts to a breach of any individual conduct requirements that: | |||
(a) apply or applied to the individual; or (b) (if the individual is or was a key function holder, a notified non-executive director or a credit union non-executive director for your firm) the individual is or was required to observe under PRA rules (including if applicable, PRA rules in force before 7 March 2016); or | |||
| (2) relates to the individual not being fit and proper to perform a function. | |||
| Answer: | |||
| Yes | |||
| No | |||
| If ‘yes’, we have provided below a description of the breaches (including dates of when they occurred) and the basis for, and outcome of, the subsequent disciplinary action. | |||
| Question G: | |||
| Are we aware of any other information that we reasonably consider to be relevant to your assessment of whether the individual is fit and proper, taking into account in particular (but not exclusively) the factors listed in SYSC 22 Annex 2 in the FCA Handbook? This disclosure is made on the basis that we shall only disclose something that: | |||
| (1) occurred or existed: | |||
(a) in the six years before your request for a reference; or (b) between the date of your request for the reference and the date of this reference; or | |||
| (2) is serious misconduct. | |||
| Answer: | |||
| Yes | |||
| No | |||
| If ‘yes’, we have provided the relevant information below. | |||
