Updated Sample Compliance Officer Form Page 2
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34. Have you at any time failed to satisfy a judgment debt under a Court Order made in
YES
NO
Trinidad and Tobago or anywhere else?
If yes, please give particulars.
5. Have you at any time, in Trinidad and Tobago or anywhere else been declared
YES
NO
bankrupt or are you the subject of any bankruptcy proceedings?
If yes, please give particulars.
6. Are you currently a Director of any company?
YES
NO
If yes, provide the name of the company, date and place of incorporation and the date of
your appointment.
7. Have you held a senior position in a company that has gone into liquidation/ receivership
YES
NO
within the past five (5) years?
If yes, please give particulars.
8. Have you ever been a senior officer of an entity in Trinidad and Tobago or elsewhere,
YES
NO
that was, during your period of association, convicted of an offence?
If yes, please give particulars.
9. Have you been approved as a Compliance Officer by any other regulator?
YES
NO
If yes, please give particulars
10. Have you held or do you currently hold the position of Compliance Officer in any other
YES
NO
entity?
If yes, please give particulars
11. Have you ever been disqualified or restricted in Trinidad and Tobago or elsewhere
YES
NO
by a court from acting as a Director of a company?
If yes, please give particulars.
12. Have you ever been dismissed or compelled to resign from any office or
YES
NO
Employment?
If yes, please give particulars.
13. Have you ever been refused entry to any professional membership/institution?
YES
NO
If yes, please give particulars.
14. Have you ever received or been exposed to any AML/CFT or compliance training?
YES
NO
If yes, please give particulars.
15.Does your previous work experience encompass elements of compliance or risk
YES
NO
management?
If yes, please give particulars inclusive of the duration of involvement
16. Have you ever been registered in any capacity under the securities law of Trinidad and
YES
NO
Tobago or another jurisdiction? If yes, please give particulars
17. Has any registration identified at item 16 above been suspended, revoked, or allowed
YES
NO
to expire? If yes, please give particulars
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