DUE DILIGENCE CHECKLIST – ENGAGEMENT OF PROFESSIONAL INTERMEDIARY

 

A.    Company Information

 

Company Details
Company Name	ACCOUNT_JOB_COMPANY
Trade name
Former name(s) – if applicable
Registered Address	ACCOUNT_ADDRESS_SINGLE_LINE
Business Address (if different)
Business License / Registration No.	ACCOUNT_COMPANY_REG_NO
Nature of Business (e.g. law firm, bank, asset manager, consulting)
Date and Place of Registration
Name of Regulator, if any
Membership with professional bodies, if any
List products or services authorized to sell or provide in the country of regulation
Internet/website
Authorised Person (For execution of this Referral Agreement other than the Directors)
Name & Designation of Contact Person	ACCOUNT_FIRST_NAMEACCOUNT_LAST_NAME
Email of Contact Person	ACCOUNT_EMAIL
Telephone of Contact Person	ACCOUNT_PHONE_NO
Due Diligence Information
Company structure (Attach a table or diagram signed by director(s) showing the ownership structure if the shareholders are non-individuals)   *Not required if Company is regulated/licensed by a financial regulator in a FATF jurisdiction.	Directors: ·         ·         ·         Shareholders: ·         ·         Ultimate Beneficial Owners (who owns 25% or more in the company): ·         ·

 

Describe the company’s risk governance structure (if not available, please indicate nil)

 

 

 

B.    Declaration

Honesty, Integrity and Reputation
1)	Has the Intermediary been refused the right or restricted in its right to carry on any trade, business or profession for which a specific license, registration or other authorization is required by law in any jurisdiction?	☐ YES ☐ NO
2)	Has the Intermediary been issued a prohibition order or has been prohibited from operating in any jurisdiction by any financial services regulatory authority?	☐ YES ☐ NO
3)	Has the Intermediary been censured, disciplined, suspended or refused membership or registration by any regulatory authority, an operator of a market or clearing facility, any professional body or government agency?	☐ YES ☐ NO
4)	Has the Intermediary been subject of any proceedings of a disciplinary or criminal nature or has been notified of any potential proceedings or of any investigation which might lead to those proceedings under any law in any jurisdiction?	☐ YES ☐ NO
5)	Has the Intermediary been convicted of any offence, or is being subject to any pending proceedings which may lead to such a conviction under any law in any jurisdiction?	☐ YES ☐ NO
6)	Has the Intermediary had any judgment (in particular that associated with a finding of fraud, misrepresentation or dishonesty) entered against it in any civil proceedings or is a party to any proceedings which may lead to such a judgment under any law in any jurisdiction?	☐ YES ☐ NO
7)	Has the Intermediary accepted civil liability for fraud or misrepresentation under any law in any jurisdiction?	☐ YES ☐ NO
8)	Has the Intermediary had any civil penalty enforcement action taken against it by any regulatory authorities under any law in any jurisdiction?	☐ YES ☐ NO
9)	Has the Intermediary contravened or abetted another person in breach of any laws or regulations, business rules or code of conduct?	☐ YES ☐ NO
10)	Has the Intermediary demonstrated an unwillingness to comply with any regulatory requirement or to uphold any professional and ethical standards?	☐ YES ☐ NO

 

 

AML/CFT policies and procedures
11)	Is the Intermediary subjected to and supervised for compliance with AML/CFT requirements by a regulatory authority?	☐ YES ☐ NO
12)	Does the Intermediary have money laundering prevention policies and procedures in place which are consistent with standards set by FATF?	☐ YES ☐ NO
13)	Does the Intermediary have an anti-bribery policy in place?	☐ YES ☐ NO
14)	If response to Q11, Q12 or Q13 is NO, does the Intermediary undertake to comply with the AML/CFT requirements in its own jurisdiction?	☐ YES ☐ NO ☐ N/A

 

 

 

Name & Acknowledgement by Intermediary / Date

 

KYC Documents to be Provided

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