BANK NEGARA MALAYSIA
APPLICATION FORM FOR MONEY SERVICE BUSINESS LICENCE
To:
Director
Money Services Business Regulation Department
Bank Negara Malaysia
Jalan Dato’ Onn
50480 Kuala Lumpur
Part 1: Type of licence applied for
Please tick (×) where applicable
Class A licence: To carry on money changing and remittance business
Class B licence: To carry on remittance business only
Class C licence: To carry on money changing business only
Class D licence: To carry on wholesale currency business only
Part 2: Applicant’s particulars
(a)
Background
Name of company
Telephone no.
BRIC no.
Fax no.
Date of incorporation
Email address
Name of contact person
Business address
Document to be enclosed:
Please tick (×) if enclosed together
with the form
1. Certified true copy of Form 9
issued by Companies
Commission of Malaysia
Business registered
address
(if address belongs to company
secretary of the applicant,
please state the name,
telephone and fax number of
secretary company)
(b)
2. Certified true copy of the
company’s M&A
Proposed shareholders and shareholding structure
If space provided is insufficient , please provide in a separate sheet
Name
(may be an individual or company)
NRIC/passport/
BRIC number
Nationality
Amount of
shareholding (RM)
Percentage of
shareholding
1.
2.
3.
4.
5.
Total
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(c)
Proposed Board of Directors, Chief Executive Officer (CEO) or key responsible person for daytoday management of the company
If space provided is insufficient , please provide in separate sheet
Name
NRIC/passport
number
Nationality
Designation/resposibility
e.g. Non-executive director, Managing director,
CEO, Manager etc
1.
2.
3.
4.
5.
(d)
Corporate structure
Applicable if applicant is part of group of companies
Please furnish the corporate structure of applicant i.e. parent/sister company and explain in brief of business
activities of each related companies in separate sheet of paper
(e)
Business plan
Please furnish business plan on separate sheet of paper. Business plan of applicant should contain, among
others:
1. Proposed location of business (full address is not required);
2. Feasibility studies on business model, potential customer, projected growth and income for the next three
years including cash flow, source of funds for business operation; and
3. Proposed governance arrangements, internal controls and risk management framework to manage the
business operations.
Please refer to Money Services Business (Licensing) Regulation 2012 for further information (available at the
Bank’s website)
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Part 3: Declaration on the information provided and consent for disclosure of information
1. The company confirms that all the information given in this document and the documents submitted are
true, and understands that if the company furnishes any information required which is false, inaccurate,
misleading or contains material errors or omissions, the licence may not be granted by Bank Negara
Malaysia (Bank). In the event that the licence has been granted, it may be revoked;
2. The company applies for a licence to carry on Money Services Business under section 5 of the Money
Services Business Act 2011 based on information provided with this application and any additional
information provided to the Bank in the course of the application; and
3. The company will promptly notify the Bank in writing of any changes in the information the company has
provided and supply any other relevant information which may come to light in the period during which its
application is being considered by the Bank. The company acknowledges that the Bank may disclose any
information provided in the performance of its statutory functions or otherwise as may be specifically
authorised by law.
I, as a person who is authorised signatory of ____________________________ (name of company) and
responsible for the management of the company:
(a) Make this solemn declaration conscientiously believing the same to be true, and by virtue of the
provisions of the Statutory Declarations Act 1960; and
(b) As provided under item(1) of Schedule 11 made in pursuant to section 134 of the Financial Services
Act 2013 (FSA), item (1) of Schedule 11 made in pursuant to section 146 of the Islamic Financial
Services Act 2013 (IFSA) and section 120(1)(c) of the Development Financial Institutions Act 2002
(DFIA),I hereby authorize any licensed business under FSA and IFSA and prescribed institutions under
DFIA where the applicant maintains its accounts, or has financial liabilities, to disclose to Bank Negara
Malaysia, any information relating to the company’s accounts and affairs including financial liabilities for
the purpose of processing this application.
___________
(Date)
______________________
(Signature)
________________________
(Name in capital letter)
__________________
(Designation)
This declaration was made before me:
______________________________
(Signature of Session Court Judge, Magistrate or Commissioner For Oaths)
Date:
Note:
Please do not enclose any payment for licence fee with the application. Licence fee is payable upon the approval of application. Applicant
will be informed in writing of the Bank’s decision on the application.
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Part 4: Form to be completed by each director/shareholder/CEO/or key responsible person of the
company applying for the money services business licence
(Please make copies of Part 4 for each individual)
(a)
Designation of key responsible person
Please tick (×) where applicable. Tick more than one box if you hold more than one position
Please attach latest
passport sized
photograph here
Director
Shareholder
Chief Executive Officer*
* Or whatever name i.e. general manager/manager who is responsible for the conduct of business and
the day-to-day management
(b)
Particulars
If the shareholder is a company/corporation, please complete relevant items in Part 4(b)
Document to be enclosed:
Please tick (×) if enclosed together
with the form
1. For individual - Certified true copy
of NRIC/passport and insolvency
report (local/foreign)
2. For company:
- Certified true copy of Form 9
issued by Companies
Commission of Malaysia (on
company registration); and
- Certified true copy of the
company’s memorandum and
association
Name
Gender (not applicable for a
company)
NRIC/Passport/BRIC no.
(whichever applicable)
Nationality (not applicable for a
company)
Current address
(for company, please state the name
of contact person)
Telephone no. (home/office)
Fax no.
Telephone no. (mobile)
Email
address
(c)
Working experience (for the last 5 years)
(for individual)
Position/designation
Organisation/company
Business activity
Duration of service
(year to year)
1.
2.
3.
4.
5.
(d)
Educational background
(for individual)
Highest level
Institution
Year obtained
1.
2.
3.
4.
5.
Page 4/7
(e)
Details of other business owned or interest owned in other business (including money services
business) (please provide additional sheet if space provided is inadequate)
Name of business
Business activity
Type of interest
(e.g. shareholder, director, partner
etc)
Amount and percentage
of shareholding owned
in other business
1.
2.
3.
4.
5.
(f)
Are any of your family members (parents, siblings, spouse and children) having interest in any
money services business? If yes, please fill the following
Name of family
member
Relationship with you
Name of money services
business
Type of interest
(e.g. shareholder, director,
partner etc)
1.
2.
3.
4.
5.
(g)
Statutory Declaration
I, _________________ (name of applicant), of NRIC / Passport No. ____________________ do solemnly and
sincerely declare that:
A:
I am not subject to the disqualifications mentioned below:
(i)
I have not been convicted of an offence under the repealed Money Changing Act 1998 [Act 577], the
Money Services Business Act 2011 [Act 731], the repealed Payment Systems Act 2003 [Act 627], the
repealed Banking and Financial Institutions Act 1989 [Act 372], the repealed Insurance Act 1996 [Act
553], the repealed Islamic Banking Act 1983 [Act 276], the repealed Takaful Act 1984 [Act 312], the
repealed Exchange Control Act 1953 [Act 17], the Financial Services Act 2013 [Act 758], the Islamic
Financial Services Act 2013 [Act 759], the Central Bank of Malaysia Act 2009 [Act 701], the
Development Financial Institutions Act 2002 [Act 618], the Anti-Money Laundering and Anti-Terrorism
Financing Act 2001 [Act 613], the Capital Markets and Services Act 2007 [Act 671] or the Companies
Act 1965 [Act 125];
(ii)
I have not been convicted of a criminal offence relating to dishonesty or fraud under any written law
within or outside Malaysia;
(iii) If I have been convicted of a criminal offence not relating to dishonesty or fraud under any written law
within or outside Malaysia, a period of five years has lapsed since the completion of my sentence*;
(iv) I am not an undischarged bankrupt;
(v) I have not suspended payments or compounded with my creditor whether in or outside Malaysia;
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(vi) (a) I have not been issued with an order of detention, supervision, restricted residence, banishment
or deportation; or
(b) I have not been imposed with any form of restriction or supervision by bond or otherwise,
under any law relating to prevention of crime, preventive detention for prevention of crime or drug
trafficking, restricted residence, banishment or immigration;
(vii) I have not held the position of a director or been directly concerned in the management of any
company which has been convicted of an offence under any written law designed to protect members
of the public against financial loss due to dishonesty, incompetence or malpractice during the tenure
of my office;
(viii) I am a person of probity, personal integrity and good reputation;
(ix) I possess the appropriate skills, experience and have sufficient knowledge of the Money Services
Business Act 2011 and the relevant provisions in the Anti-Money Laundering and Terrorism
Financing Act 2001 to effectively fulfil the role and responsibilities of the position;
(x) I have managed my affairs properly and prudently; and
(xi) If I am to be appointed as a chief executive officer or to be primarily responsible for the day-to-day
management of the company, I will be available for full time employment.
B:
I am*:
(i)
(ii)
C:
representing the interest of __________________; or
not representing the interests of any person;
All the information submitted above is true.
This declaration was made before me:
(Signature of Sessions Court Judge, Magistrate or Commissioner For Oaths)
Date:

Delete whichever not applicable/relevant
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Part 5: Consent for Disclosure of Information
Please complete where applicable:
1. For individual who has completed Part 4 of this form.
As provided under item(1) of Schedule 11 made in pursuant to section 134 of the Financial Services Act
2013 (FSA), item (1) of Schedule 11 made in pursuant to section 146 of the Islamic Financial Services Act
2013 (IFSA) and section 120(1)(c) of the Development Financial Institutions Act 2002 (DFIA),I hereby
authorize any licensed business under FSA and IFSA and prescribed institutions under DFIA where the
applicant maintains its accounts, or has financial liabilities, to disclose to Bank Negara Malaysia, any
information relating to the company’s accounts and affairs including financial liabilities for the purpose of
processing this application.
______________
(Date)
_________________
(Signature)
_____________________
(Name in capital letter)
__________________
(Designation)
2. For a company (corporate shareholder) which has completed Part 4 of this form.
As provided under item(1) of Schedule 11 made in pursuant to section 134 of the Financial Services Act
2013 (FSA), item (1) of Schedule 11 made in pursuant to section 146 of the Islamic Financial Services Act
2013 (IFSA) and section 120(1)(c) of the Development Financial Institutions Act 2002 (DFIA), I on behalf of
the company (as a shareholder) hereby authorize any licensed business under FSA and IFSA and
prescribed institutions under DFIA where the applicant maintains its accounts, or has financial liabilities, to
disclose to Bank Negara Malaysia, any information relating to the company’s accounts and affairs including
financial liabilities for the purpose of processing this application.
[Consent should be given by the director/CEO who is responsible of the management of the company].
_____________
(Date)
_________________
(Signature)
_____________________
(Name in capital letter)
__________________
(Designation)
IMPORTANT:
BANK NEGARA MALAYSIA MAY REQUEST FOR ADDITIONAL INFORMATION AS AND
WHEN REQUIRED
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