PSD Agent Form - DOC by qWYuN1sn


									                                            Application number
                                              (for FSA use only)


Add PSD agent
Application under regulation 29 of the Payment Services Regulations

            Name of payment institution

         Firm reference number (FRN)


The Financial Services Authority
Permissions, Decisions & Reporting Division
25 The North Colonnade
Canary Wharf
London. E14 5HS
United Kingdom

Telephone        +44 (0) 845 606 9966
Facsimile        +44 (0) 207 066 0017

Registered as a Limited Company in England and Wales No 1920623. Registered Office as above

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This form should only be used to notify us of a new agent of a Small Payment Institution or an
Authorised Payment Institution. It is the responsibility of the payment institution to complete and
submit this form on behalf of the agent.

 Section 1 – Personal details

 1.01    Contact name at the payment institution
         (this is not necessarily the same person making the
         declaration at the end of the form)
 1.02    Contact details:



             Individual reference number (IRN)
             - if applicable

Section 2 – Agent details

 2.01    Name

 2.02    Firm reference number (FRN)
         - if applicable
 2.03    Address (include country if not UK)


 2.04    Trading name(s), if different to the name
         given in question 2.01

 2.05    Telephone

 2.06    Fax

 2.07    Email

 2.08    Website (not mandatory)

 2.09    Legal status
         Private limited company                                    Public limited company

         Partnership                                                Limited partnership

         Limited liability partnership                              Unincorporated association

         Sole trader                                                Other (please specify below)

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                                                                                                  Yes     No
 2.10   Authorised Payment Institutions only
        Will the Authorised Payment Institution be engaging the agent to provide
        payment services in another EEA State(s)?

        If No proceed to Section 3. If Yes we will link this agent to the ‘right to establish’
        passports held by the Authorised Payment Institution for any EEA State given in
        question 2.03. If this agent will have an establishment in, or provide services
        into, any other EEA State you will need to supply this information on a separate
        sheet of paper, specifying for each EEA State:

              whether the agent will have an establishment or will provide cross-border
               services; and
              the payment services that will be provided.

Firms wishing to appoint an agent need to provide a description of the internal control mechanisms
that will be used by the agent to comply with money laundering legislation. For more information on
the type of money laundering controls we expect to see being used by firms and their agents, please
refer to Chapter 3 of the Approach Document.

 Section 3 – Money laundering controls
                                                                                                   Yes    No
 3.01   Has the firm already supplied to us, as part of another application, a description
        of the money laundering controls that will be used by all their agents, and do you
        confirm that those controls will be used by this agent?
        If No please provide below a description of the internal money laundering controls to be used
        by this agent to comply with money laundering legislation.
        If Yes proceed to Section 4.

                              Please indicate how many additional sheets are being submitted

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 Section 4 – Directors/persons responsible for payment services

                                                                                                       Yes    No
         Is this application being made on behalf of an agent of an Authorised Payment
 4.01    Institution?
        If Yes please complete the following table for the proprietor, director(s)/partner(s) and
        person(s) responsible for the management of the agent. If No please go to Section 5.

        Please state the number of individuals linked to this agent

         Full name of individual             National Insurance (NI)          Date of       Assessed Anything
         Including:                                 number                     birth         as a fit      to
                                                                             (dd/mm/yyyy)     and      disclose
            previous name(s)                  (Please provide passport
            Date(s) of any name change(s)    number and nationality if NI                   proper   in relation
            commonly known-by names
                                                number is not available)                     person to Annex 1

                                                                                            Yes   No    Yes   No
                                                                              /   /

                                                                              /   /

                                                                              /   /

                                                                              /   /

                                                                              /   /

                                                                              /   /

 4.02    If the firm has anything to disclose for any individual, whether in relation to Annex 1 or
         otherwise, please provide further information on a separate sheet of paper, clearly identifying
         the individual(s) it relates to.


Please see Annex 1 for the questions that we expect you to ask of each of the above individual(s) to
assess their fitness and propriety. This list is not exhaustive and you should advise individual(s) to
disclose to you any issues that could affect their fitness and propriety.

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Section 5 – Declaration and signature

Knowingly or recklessly giving the FSA information that is false or misleading in a material particular,
may be a criminal offence (regulation 114 of the Payment Services Regulations 2009) and may lead to
disciplinary sanctions or other enforcement action by the FSA.
It should not be assumed that information is known to the FSA merely because it is in the public
domain or has previously been disclosed to the FSA or another regulatory body. If you are not sure
whether a piece of information is relevant, please include it anyway.

Data protection
For the purposes of complying with the Data Protection Act 1998, the personal information in this form
will be used by the FSA to discharge its statutory functions under the Payment Services Regulations
2009 and other relevant legislation. It will not be disclosed for any other purposes without the
permission of the applicant.

By submitting this notification:
       I confirm that this information is accurate and complete to the best of my knowledge and belief
        and that I have taken all reasonable steps to ensure that this is the case.
       I am aware that it is a criminal offence to knowingly or recklessly give the FSA information that
        is false or misleading in a material particular.
       I am aware that some questions do not require supporting evidence. However, the records
        that demonstrate the applicant firm's compliance with the requirements in relation to the
        questions are available to the FSA on request.
       I will notify the FSA immediately if there is a significant change to the information given in the
        form. If I fail to do so, this may result in a delay in the application process or enforcement

                                      Date      /   /



    Individual Reference Number (IRN)
                              - if applicable


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Annex 1 – Fitness and propriety

1.01   a Has the individual ever been convicted of any offence (that is unspent and whether or not in
          the UK):

           i.    involving fraud, theft, false accounting, offences against the administration of public
                 justice (such as perjury, perverting the course of justice and intimidation of witnesses
                 or jurors), serious tax offences or other dishonesty; or

           ii.   relating to payment services, companies, building societies, industrial and provident
                 societies, credit unions, friendly societies, insurance, banking or other financial
                 services, insolvency, consumer credit or consumer protection, money laundering,
                 market manipulations or insider dealing?

       b Is the individual the subject of any current criminal proceedings?

1.02      Has the individual any unspent convictions for any offences (whether or not in the UK) other
          than those in 1.01 (excluding traffic offences that did not result in a ban from driving or did
          not involve driving without insurance)?

1.03   a Has the individual ever had a County Court Judgment (CCJ) or other judgment debt,
          (whether or not in the United Kingdom)?

          Has the individual had:

           i.    more than two CCJs or judgment debts?

           ii.   more than £1,000 in total of CCJs or judgment debts?

       b Is the individual aware of anybody's intention to:
           i.    begin proceedings against the individual for a CCJ or other judgment debt?

           ii.   begin more than one set of proceedings against the individual for a CCJ or other
                 judgement debt?

          iii.   claim more than £1,000 of CCJs or judgment debts in total from the individual?

1.04      Does the individual have any judgment debts (including CCJs) made under a court order
          still outstanding, whether in full or in part?

1.05      Has the individual ever failed to satisfy any such judgment debts within one year of the
          making of the order?

1.06   a Is the individual, or has the individual ever been, the subject of any bankruptcy proceedings
          or proceedings for the sequestration of the individual’s estate?

       b Has the individual ever entered or are they in the process of entering into an agreement in
          favour of the individual's creditors, for example a deed of arrangement or an individual
          voluntary arrangement (or in Scotland a trust deed)?

       c Have any of the above not discharged?
1.07      Does the individual have any outstanding financial obligations arising from regulated
          activities, which the individual has carried on in the past (whether or not in the UK or
          (In the case of advisers, this will include any outstanding liabilities arising from commissions paid for
          the sale of packaged products that have lapsed.)

1.08      Has the individual ever been found guilty of carrying-on any unauthorised regulated
          activities, or been investigated for the possible carrying-on of unauthorised regulated

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1.09       Is the individual, or has the individual ever been, the subject of an investigation into
           allegations of misconduct or malpractice in connection with any business activity?

1.10       Has the individual ever (whether or not in the United Kingdom):
       a       been refused entry to, or been dismissed, suspended or requested to resign from, any
               profession, vocation, office or employment, or from any fiduciary office or position of
               trust, whether or not remunerated?
       b       been refused, restricted in, or had suspended, the right to carry on any trade, business
               or profession for which specific licence, authorisation, registration, membership or other
               permission is required?
       c       been disqualified from acting as a director of a company, or from acting in a
               management capacity, or conducting the affairs of any company, partnership or
               unincorporated association?
       d       been the subject of a disqualification direction under section 59 of the Financial Services
               Act 1986, or a prohibition order under section 56 of the Financial Services and Markets
               Act 2000, or received a warning notice that such a direction or order be made?

1.11       In relation to activities regulated by the FSA or another regulatory body (see Section 5),

             i.    the individual; or

             ii.   any company, partnership or unincorporated association of which the individual is or
                   has been a controller, director, senior manager, partner or company secretary, during
                   the individual’s association with that entity and for a period of three years after the
                   individual ceased to be associated with it, ever:

       a       been refused, had revoked, restricted or terminated, any licence, authorisation,
               registration, notification, membership or other permission granted by any such body?

       b       been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of
               any other disciplinary or intervention action by any such body?

       c       resigned while under investigation by, or been required to resign from, any such body?

       d       decided, after making an application for any licence, authorisation, registration,
               notification, membership or other permission granted by any such body, not to proceed
               with it?

       e       been the subject of any civil action, which has resulted in a finding against the candidate
               or it by a court?

1.12       Has any company, partnership, or unincorporated association of which the individual is or
           has been a controller, director, senior manager, partner, or company secretary, in the UK or
           elsewhere, at any time during the individual’s involvement or within one year of such an

       a            been put into liquidation, wound up, ceased trading, had a receiver or administrator
                    appointed or entered into any voluntary arrangement with its creditors?

       b            been adjudged by a court liable for any fraud, misfeasance, wrongful trading or
                    other misconduct?

       c            been investigated or been involved in an investigation by an inspector appointed
                    under companies or any other legislation, or required to produce documents to the
                    Secretary of State, or any other authority, under any such legislation?

       d            been convicted of any criminal offence, censured, disciplined or publicly criticised,
                    by any inquiry, by the Takeover Panel or any governmental or statutory authority or
                    any other regulatory body (other than as already indicated under 1.11(b))?

1.13       Is the individual aware of any business interests, employment obligations, or any other
           situations that may conflict with the performance of the position for which approval is now

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