Fit And Proper Assessment Form

FIT AND PROPER ASSESSMENT FORM

Assessing Entity Name:    Applicant Name:    Position Applied For:

Assessment Reference No.:    Assessment Date:

RECITALS

WHEREAS the Applicant has applied to the Assessing Entity for appointment to the position specified above and has provided information and documentary evidence to support the application; and

WHEREAS the Assessing Entity is required to determine whether the Applicant satisfies the Fit and Proper criteria established by the Assessing Entity and applicable regulatory standards, including honesty, integrity, competence and financial soundness; and

WHEREAS the parties record their respective statements and certifications in this Fit and Proper Assessment Form to permit a reasoned decision and to create an auditable record of the assessment;

NOW THEREFORE

In consideration of the declarations, representations and undertakings set out below, the Assessing Entity will evaluate the Applicant against the criteria and will record a determination in accordance with this Form.

1. DEFINITIONS

For the purposes of this Form, "Applicant" means the individual named in applicant_name; "Assessing Entity" means the organisation named in assessing_entity_name; "Fit and Proper" means possessing the honesty, reputation, competence, capability and financial soundness necessary to perform the duties of the position without material risk to the Assessing Entity or its stakeholders.

2. APPLICANT INFORMATION

3. PROFESSIONAL QUALIFICATIONS

4. FINANCIAL INTEGRITY

Has the Applicant ever been declared bankrupt, subject to insolvency proceedings or had a personal financial judgement entered against them?    Yes    No

5. CRIMINAL AND REGULATORY HISTORY

Has the Applicant been convicted of any criminal offence, or subject to regulatory enforcement action, disciplinary sanction, professional censure or removal from office?    Yes    No

6. CONFLICTS OF INTEREST

Does the Applicant currently hold any other directorships, significant shareholdings, or positions that may give rise to a conflict with the duties of the proposed role?    Yes    No

7. FIT AND PROPER CRITERIA — ASSESSMENT

The Assessor must evaluate the Applicant against the following matters and provide a reasoned comment and conclusion for each. Check the assessor's view and provide comments.

Assessor view:    Satisfactory    Unsatisfactory

Assessor view:    Satisfactory    Unsatisfactory

Assessor view:    Satisfactory    Unsatisfactory

8. DECLARATION AND CERTIFICATION BY APPLICANT

The Applicant certifies that the information provided in this Form is true, complete and not misleading. The Applicant undertakes to notify the Assessing Entity promptly of any material change to the information provided and consents to such enquiries and checks as the Assessing Entity considers necessary to verify the contents of this Form.

9. ASSESSOR'S FINDINGS AND RECOMMENDATION

Summary of factual findings supporting the assessor's view (include sources relied upon and any limitations of the review):

Recommendation:    Approve appointment    Do not approve appointment    Approve subject to conditions

10. CONFIDENTIALITY, NOTICES, AMENDMENTS

The information contained in this Form is confidential and may only be used for the purposes of the assessment and for compliance with applicable legal or regulatory obligations. Notices under this Form must be in writing and delivered to the addresses recorded above. Any amendment to this Form must be recorded in writing and signed by authorised representatives of both parties.

11. WAIVER, COUNTERPARTS

No failure or delay by either party in exercising any right under this Form shall operate as a waiver. This Form may be executed in counterparts, each of which constitutes an original and all of which together constitute one and the same instrument.

12. GOVERNING LAW, ENTIRE AGREEMENT, SEVERABILITY

This Form is governed by the laws of the jurisdiction specified by the Assessing Entity. This Form constitutes the entire record of the Fit and Proper assessment between the parties and supersedes any prior oral or written statements regarding the matters addressed herein. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

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