Boulevard de Berlaimont 14 – BE-1000 Brussels
tel. +32 2 221 38 12 – fax + 32 2 221 31 04
Company number: 0203.201.340
RPM (Trade Register) Brussels
www.bnb.be
Brussels, 17 June 2013
Appendix 1 to circular NBB_2013_02
Form 1 “New appointment”
Scope
Credit institutions, stockbroking firms, payment institutions, electronic money institutions,
settlement institutions, institutions equivalent to settlement institutions, (re)insurance
companies, (mixed) financial holding companies, insurance holding companies and certain
branches.
Any personal data submitted on this form will be processed by the National Bank of Belgium
(NBB), Boulevard de Berlaimont 14, 1000 Brussels, in accordance with the Law of
8 December 1992 on the protection of privacy with regard to the processing of personal data.
The NBB will process these data for the purposes of verifying compliance with the legal
provisions set out below.
The processed data may be passed on to third parties, where appropriate, only under the
conditions set out in Articles 36/13 and 36/14 of the Law of 22 February 1998 establishing the
Organic Statute of the National Bank of Belgium.
Within the limits provided for in the regulations concerning the protection of privacy, the natural
persons whose personal data have been processed have the right to inspect and correct such
data in accordance with Articles 10 and 12 of the aforementioned Law of 8 December 1992.
Preliminary remarks
1)
Completeness and accuracy of the information sent
The NBB expects both the applicant in question and the institution to answer the questions below
accurately and to provide any relevant and material information of which they are aware. If the NBB
finds that any incomplete or inaccurate information has been sent intentionally, this will lead to a
negative assessment of the suitability of the person in question. In relation thereto, we refer readers
specifically to points 5.1 and 7.3 of circular NBB_2013_02.
In this respect, it is also important to note that the answers to the questions set out below need to
deal with all elements relating to the situation of the person in question, both in Belgium and abroad.
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 1/26
Space is provided under certain questions to fill in additional information if the answer to the question is
affirmative. If the provided space is insufficient, please add further enclosures, numbering them clearly
and listing them in TITLE VIII of this form.
If some of the information sent should so require, or if the person in question should so wish, s/he
may make any additional comments which s/he may deem to be relevant verbally to the NBB.
The NBB furthermore offers a reminder that Articles 108 of the Law of 22 March 1993, 152 of the Law of
6 April 1995, 210 of the Law of 20 July 2004 and 88 of the Law of 9 July 1975 authorize the Bank to
obtain information from the judicial authorities concerning any conviction for or investigation into an
infringement of the Laws of 22 March 1993, 6 April 1995, 9 July 1975 or 20 July 2004, or to any of the
legislation mentioned in Articles 19 of the Law of 22 March 1993, 61 of the Law of 6 April 1995, or 39 and
152 of the Law of 20 July 2004. If any changes should take place subsequently with regard to the
answers given in this form, details of them must be sent to the NBB using form 3 “NEW ELEMENTS”.
2)
Information already sent previously relating to professional integrity as a result of the
holding of another position, whether at the same financial institution or not.
With regard to the information requested in TITLE VI of this form (information about the professional
integrity of the person in question), it is permissible to refer to an identical or similar form previously
submitted to the NBB. Nevertheless, this may only be done if no changes need to be made to the
answers contained in the previous form. In this case, no answers must be given to questions 2 to 9
inclusive under TITLE VI.
If the said option is being used, please identify the form mentioned precisely in question 1.
Appendix 1 – Page 2/26
NBB_2013_02 – 17 June 2013
TITLE I. CONTACT DETAILS OF THE INSTITUTION
Please fill in the contact details of the institution at which the person to be appointed wishes to hold a
position which falls within the scope of the law.
1. Name of the institution
2. Address
3. Telephone and fax numbers
4. Company number
5. Nature of the institution
credit institution
stockbroking firm
payment institution
electronic money institution
settlement institution
institution equivalent to a settlement institution
insurance company
reinsurance company
financial holding company
insurance holding company
mixed financial holding company
If applicable
foreign branch of a Belgian institution ("outward
passporting")
Belgian branch of a foreign institution
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 3/26
TITLE II. PERSONAL DATA
1. Surname
2. First name(s)
3. Place and date of birth
4. Gender
5. Nationality
6. Domicile
7. Place of residence (if different
from the domicile mentioned
in point 6.)
8. Telephone/ Mobile phone
number
9. E-mail address
Appendix 1 – Page 4/26
NBB_2013_02 – 17 June 2013
TITLE III. SCREENINGS BY THE NBB, THE FSMA AND FOREIGN
FINANCIAL SUPERVISORY AUTHORITIES
1.
Has the person in question ever undergone a suitability assessment by the NBB
in the past or is s/he currently undergoing this type of assessment for the
purposes of another position?
YES
NO
YES
NO
YES
NO
YES
NO
If so, please give details about this screening below.
2.
Has the person in question ever undergone a suitability assessment by another
financial supervisory authority or is s/he currently undergoing this type of
assessment for the purposes of another position?
If so, please give details about this screening below.
3.
Has the person in question ever in the past withdrawn an application for a
position which had been made to either the NBB or another financial supervisory
authority?
If so, please give details about this withdrawal below.
4.
Has the person in question ever been accredited by the FSMA as a compliance
officer, or is there an accreditation procedure of this kind in progress at the
present time?
If so, please give details about the accreditation obtained or the ongoing
accreditation procedure below.
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 5/26
TITLE IV. DATA RELATING TO THE POSITION
A.
General points
1. a) Please state below the position which the person in question wishes to hold within the
institution.
Please check all boxes which apply to the person in question.
executive director
non-executive director
chairman of the management body
chairman of the audit committee
chairman of the remuneration committee
chairman of the risk committee
chairman of the nomination committee
member of the management committee
chairman of the management committee
senior manager of an institution with no management committee
senior manager of a branch
head of the compliance function
head of the internal audit function
head of the risk management function
head of the actuarial function
b) Please state the official title of the position within the institution.
Official title of the position
2. Please give below as detailed as possible a description of the main duties, skills and
responsibilities relating to the position in question. Please specify which other functions, if any, the
person involved will exercise within the institution. Please also specify on which subcommittees of
the management body or other committees the person involved will sit, if applicable.
Appendix 1 – Page 6/26
NBB_2013_02 – 17 June 2013
3. Please give below additional details about the planned start date and the length of the term of office.
Planned start date for the appointment
Planned term of office
Is the person to be appointed replacing
somebody else?
If so, who and why?
B. Position as a non-executive director
If this is a position as a non-executive director, please state the capacity in which the person in question
is to be appointed.
as a shareholder, cooperant or a mutual member of this institution
as the representative of a shareholder, a cooperant or a mutual member of this institution
as an independent director within the meaning of Article 526ter of the Companies Code. 1
in some other capacity.
In this latter case, please explain the capacity more precisely.
1
Please remember that it is incumbent upon the institution to check that all of the legal criteria set out in
Article 526ter of the Companies Code have been fulfilled.
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 7/26
TITLE V. INFORMATION ABOUT THE EXPERTISE OF THE PERSON IN
QUESTION
1. Education
Please fill in the table below with information about the education of the person in question, starting with
the most recent events.
Name of the institution
Start date
Month
Year
End date
Month
Diploma obtained
Year
2. Other important training
Please fill in the table below with information about any other important training undertaken by the person
in question, starting with the most recent.
Name of the institution
Start date
Month
Appendix 1 – Page 8/26
Year
End date
Month
NBB_2013_02 – 17 June 2013
Year
Object of the training
3. Professional experience working for companies in the financial sector
Please fill in the table below with information about the professional experience acquired by the person in
question working for companies in the financial sector over the last eight years.
Company name
and area of
business
Description and title
of the position held
Start date
Month
Year
End date
Month
Year
Reason for
leaving the
company
4. Management experience or experience in independent control functions
Please fill in the table below with information about any management experience or experience in
independent control functions acquired by the person in question in companies over the last eight years.
Company name and
area of business
Description and title
of the position held
Start date
Month
Year
NBB_2013_02 – 17 June 2013
End date
Month
Year
Reason for
leaving the
company
Appendix 1 – Page 9/26
5. Other professional experience
Please fill in the table below with information about any professional experience over the last eight years
which has not been mentioned in the tables for questions 3 and 4.
Company name and
area of business
Description of the
position held
Start date
Month
Year
End date
Month
Year
Reason for
leaving the
company
6. Non-competition clauses or other binding undertakings
Please state whether the person in question is bound by any non-competition clauses or by any other
binding commitment by reason of any position previously held.
7. Periods without engaging in any professional activities
Up until the present time, has there been one or more periods of at least twelve months in the
professional career of the person in question during which s/he has not engaged in any
professional activity?
If so, please give details about these periods of inactivity below.
Appendix 1 – Page 10/26
NBB_2013_02 – 17 June 2013
YES
NO
8. References
Please give contact details for at least two referees in the table below.
If possible, one of them should represent a previous employer. By mentioning these persons, you formally
authorize the NBB to contact them. You will be informed prior to any such contact.
The following persons may not be given as referees: parents or relatives either by blood or by marriage in
a direct or collateral line and up to the third degree, spouses, (cohabiting) partners or close friends.
1
2
3
Surname and first
name
Address
Telephone/ Mobile
phone number
Position
Relationship to the
person in question
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 11/26
TITLE VI. INFORMATION ABOUT THE PROFESSIONAL
INTEGRITY OF THE PERSON IN QUESTION
1. Please state whether any information about the professional integrity of the person to be appointed
has ever been sent in the past.
The person in question has already sent the NBB the information requested in TITLE VI by
sending the NBB an identical or similar form.
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
If so, please state, as precisely as possible, when and within what context (institution and position in
question) this information was sent.
(only to be completed in the event of an answer in the affirmative to the first paragraph) As no
changes need to be made to this previous information, the person in question refers to this form in
answer to the questions set out in this title.
(only to be completed in the event of an answer in the affirmative to the first paragraph) The party
in question hereby states that s/he has previously sent the NBB an “extrait du casier judiciaire” (a
criminal records certificate), or an equivalent document issued by a foreign authority, dating back
less than three months, in appendix to this identical form or a similar form sent previously.
(only to be completed in the event of an answer in the affirmative to the first paragraph) As the
person in question has not been convicted since that time, the “extrait du casier judiciaire”
mentioned, or the equivalent document issued by a foreign authority, remains valid.
There is no need to answer questions 2 to 11 in the event of answers in the affirmative to all of the
previous paragraphs.
2. Criminal convictions (either in Belgium or abroad)
Do you have any criminal convictions or, to the best of your knowledge, has there ever been a
criminal investigation of which you were the subject either in Belgium or abroad?
If so, please give the necessary details below.
In this respect, please make a clear distinction between any previous convictions and any cases which
are still ongoing.
Please enclose the case number and copies of any procedural documents you may have with this form.
Appendix 1 – Page 12/26
NBB_2013_02 – 17 June 2013
Previous convictions:
Cases still ongoing:
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 13/26
3. Negative assessments by financial supervisory authorities (either in Belgium or abroad)
a. Has a financial supervisory authority ever considered or declared that you do not have the
required professional integrity or expertise to hold a position in an institution which is subject to
(prudential) supervision?
YES
NO
b. Are you aware of any accusations which have been made or are being made against you by a
financial supervisory authority?
YES
NO
If you answer in the affirmative to any of these questions, please give the necessary details below.
Appendix 1 – Page 14/26
NBB_2013_02 – 17 June 2013
4. Administrative or disciplinary measures (either in Belgium or abroad)
To the best of your knowledge, have you been or are you subject to one or more
administrative or disciplinary measures or to one or more similar administrative measures as
part of your professional activities, or a measure involving suspension or expulsion from a
professional organisation? To the best of your knowledge, are there any such proceedings in
progress against you?
YES
If you answer in the affirmative, please give the necessary details below.
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 15/26
NO
5. Dismissal or termination of contract on grounds of serious misconduct (either in Belgium or abroad)
Have you ever been dismissed on grounds of serious misconduct, or has a contract of
independent agent or any other contract under which you carried out a professional activity as a
self-employed person ever been terminated for serious misconduct?
If you answer in the affirmative, please give the necessary details below.
Appendix 1 – Page 16/26
NBB_2013_02 – 17 June 2013
YES
NO
6. Companies / institutions / bodies at which you hold or have held a position which falls within the scope
of the law, or where you influence or have influenced policy in another significant way, or in which you
hold or have held a significant interest
a. Has a company of this kind / an institution of this kind / a body of this kind ever been
the subject of a criminal conviction, of an administrative or disciplinary measure or
an equivalent administrative measure, or of a measure involving suspension or
exclusion by a professional organisation?
To the best of your knowledge, are there any proceedings of this kind
ongoing against a company of this kind /an institution of this kind / a
body of this kind?
b. Has a company of this kind / an institution of this kind / a body of this kind ever
been the subject of a refusal or withdrawal of authorization?
YES
NO
YES
NO
YES
NO
If you answer in the affirmative to any of these questions, please give the necessary details below. Please
also precisely identify the company / institution / body in question by giving its VAT number or, failing this,
its national number. As far as question 6.a. is concerned, a distinction should be made between any
previous convictions or measures and any cases which are still ongoing.
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 17/26
7. Public aid
Has a company / institution / body at which you hold or have held a position which falls within
the scope of the law, or where you influence or have influenced policy in another significant
way, or in which you hold or have held a significant interest received public aid?
YES
If you answer in the affirmative, please give the necessary details below. Please also precisely identify
the financial institution in question.
Appendix 1 – Page 18/26
NBB_2013_02 – 17 June 2013
NO
8. Settlements or agreements
a. Have you ever been or are you considering being party to a settlement or
agreement in a dispute with third parties relating to an infringement of financial
or other legislation?
b. Has a company / institution / body at which you hold or have held a position
which falls within the scope of the law, or where you influence or have
influenced policy in another significant way, or in which you hold or have held a
significant interest, ever been party to a settlement or agreement in a dispute
with third parties relating to an infringement of financial or other legislation, or is
such company/ institution/ body considering such a move?
YES
NO
YES
NO
YES
NO
YES
NO
If you answer in the affirmative to any of these questions, please give the necessary
details below. Please also precisely identify the company / institution / body in
question by giving its VAT number or, failing this, its national number.
9. Adjustment or discharge of either personal debts or a company’s debts
a. Have you taken part or do you plan to take part in an amicable settlement or a
judicial procedure relating to an adjustment and/or a discharge of personal
debts?
b. Have you taken part or do you plan to take part in an amicable settlement or a
judicial procedure relating to an arrangement and/or a clearing of the debts of
a company / institution / body at which you hold or have held a position which
falls within the scope of the law, or where you influence or have influenced
policy in another significant way, or in which you hold or have held a
significant interest?
If you answer in the affirmative to any of these questions, please give the necessary details below.
Please also precisely identify the company / institution / body in question by giving its VAT number
or, failing this, its national number.
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 19/26
10.
Bankruptcy
Has a company / an institution / a body at which you have held a position which falls
within the scope of the law, or where you have significantly influenced the policy in
another way, or in which you have held a significant interest, ever been declared
bankrupt?
To the best of your knowledge, is there any such proceeding ongoing with regard to a
company of which you are asenior manager or in which you have a significant
interest?
YES
If you answer in the affirmative, please give the necessary details below (e.g. the exact date of the
declaration of bankruptcy). Please also precisely identify the company / institution / body in question by
giving its VAT number or, failing this, its national number.
Appendix 1 – Page 20/26
NBB_2013_02 – 17 June 2013
NO
11. Refusal to certify company accounts
Have external auditors (accredited auditor(s), statutory auditor(s), etc.) ever refused to certify
the accounts of a company / institution / body at which you hold or have held a position
which falls within the scope of the law, or where you influence or have influenced policy in
another significant way, or in which you hold or have held a significant interest?
YES
NO
If you answer in the affirmative, please give the necessary details below.
Please also precisely identify the company in question by giving its VAT number or, failing
this, its national number.
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 21/26
12. Financial or non-financial interests or relationships
Do you and/ or your close relatives have any financial (e.g. loans, shareholdings) or nonfinancial interest to or relationship with (e.g. close relations like a spouse, registered partner,
cohabite, child, parent or other relation with whom you share living accommodations)
members of the management body and key function holders in the same credit institution,
the parent institution and subsidiaries and controlling shareholders?
If you answer in the affirmative, please indicate the financial or non-financial interests or
relationships below.
Appendix 1 – Page 22/26
NBB_2013_02 – 17 June 2013
YES
NO
TITLE VII. OTHER INFORMATION ABOUT THE PERSON IN QUESTION
1. Outside employment and/or other professional activities
Please answer the following questions by checking the YES or NO boxes. Your answers must relate to your
situation both in Belgium and abroad. If you answer in the affirmative, please provide any relevant details
in a separate enclosure (including identification of the other company, a description of the other position or
activity and the start date for this position or activity).
In addition to the position which is the subject of this form, have you any plans to
continue or start carrying out other positions which involve taking part in the
management or policy function of another company?
YES
NO
In addition to the position which is the subject of this form, do you have any plans
to continue or start carrying out other professional activities, acting in any capacity
whatsoever (employee, self-employed, etc.) ?( 1)
YES
NO
Are you aware of any conflict of interest, a professional obligation or any other
situation relating to yourself and which might potentially come into conflict with the
position which is the subject of this form?
YES
NO
YES
NO
If you answer in the affirmative to one or several of the above questions, please
provide the necessary information below. Please give further details regarding the
time distribution.
2. Additional information
Do you believe you need to provide any other information which might be relevant
to the appraisal of your application?
If you answer in the affirmative, please provide this information below.
(1) If you answer this question in the affirmative, we would like to draw your attention to the legal provisions on the
incompatibility of offices held and to the circular concerning the holding of outside positions
(circular PPB-2006-13-CPB-CPA of 13 November 2006 relating to the holding of outside positions by officers of
regulated companies)).
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 23/26
TITLE VIII. ENCLOSURES
1. Compulsory enclosures
This form must be accompanied by a series of enclosures, in English whenever possible. Using the
checklist below, please state which of these documents you have enclosed.
•
Enclosure 1: a legible copy of a valid passport or identity card for the person to be appointed
•
Enclosure 2: the curriculum vitae of the person to be appointed
•
Enclosure 3: an “extrait du casier judiciaire” or an equivalent document issued by a foreign
authority, dating back less than three months and concerning the person to be appointed
•
Enclosure 4: an organisational chart for the financial institution in question mentioning the position
in question, the composition of the bodies and subcommittees and, if the person is to be appointed
as a director, a detailed description of the division of tasks within the management body
•
Enclosure 5: the function profile drawn up by the institution
•
(where applicable) Enclosure 6: a document relating to the assessment of the person in question by
another financial supervisory authority
2. Other enclosures
Please list below any other enclosures which you are sending with this form.
Please identify each enclosure precisely, stating the number of pages of which each of them is made
up, and please also precisely state the number of the question to which each enclosure relates.
The enclosures must each bear a specific sequential number.
Appendix 1 – Page 24/26
NBB_2013_02 – 17 June 2013
Declaration made by the applicant in question
“I, the undersigned ……………………………………….....……………….....................................................
(surname and first name(s) of the applicant in question), hereby declare that I have replied to the
questions above accurately and in good faith.
I hereby undertake to inform the institution in question immediately of any change in relation to one or
more of the answers to these questions.
I also note that the deliberate providing of inaccurate and/or incomplete information will have a negative
impact upon the appraisal of my application or, subsequently, the qualities required of me for the
purposes of holding the position in question.
I hereby declare that I shall be holding the position in question in my own name.”
Date and signature of applicant in question
NBB_2013_02 – 17 June 2013
Appendix 1 – Page 25/26
Declaration made by the institution in question
“Acting in my capacity:
as chairman of the management body
as chairman of the management committee
as a non-executive director
as asenior manager of the foreign institution to which the senior manager of the branch in Belgium
directly reports
of ………………………………………………...............……………….. (name of the institution in question),
I, the undersigned, ……………………………………....………….............................…….. (surname and
first name(s)) hereby declare, after having made the usual verifications, that the information provided by
………………………………………………....................……………………. (applicant's surname and first
name(s)) to the National Bank of Belgium for the purposes of this form is accurate to the best of my
knowledge.
……………………………………………….............................……….. (name of the institution in question)
hereby undertakes to immediately inform the National Bank of Belgium of any and all changes to the
details contained in this form of which it may become aware and which would be likely to have an impact
upon the appraisal of the applicant’s suitability by the National Bank of Belgium. For this purpose it will
use form 3 “NEW ELEMENTS”.
Date, title and signature
Appendix 1 – Page 26/26
NBB_2013_02 – 17 June 2013