BANK NEGARA MALAYSIA
APPLICATION FORM FOR NEW SHAREHOLDER
Notes on completion
I. Please complete the form for shareholder with a holding of 5% or more.
II. Part II must be completed by an individual who qualifies to apply to be a Shareholder of the
company.
III. Part III to be completed by a corporate shareholder.
IV. Part IV to be completed by existing Board of Directors of the company
V. The completed Application Form and documents should be submitted to:
The Director
Money Services Business Regulation Department
Tingkat 12, Blok C
Bank Negara Malaysia
Jalan Dato’ Onn
50480 Kuala Lumpur
Part I: Applicant’s particulars
Name of company
Business address
Telephone no.
Fax no.
Part II: Details of the proposed new Shareholder (Individual)
Name
Nationality
NRIC/Passport No.
Please attach latest
passport sized
photograph here
Current address
Telephone no. (home/office)
Telephone no. (mobile)
Fax no.
E-mail address
Supporting documents to be
enclosed:
Please tick (×) if enclosed
together with the form
Malaysian citizen:
Photocopy of MyKad (front
and back)
Non-Malaysian citizen:
Photocopy of the 1st page of
Passport (the personal
particulars only) or MyPR
(front and back)
Latest Insolvency Report
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(a)
Working experience (for the last 5 years)
Position/designation
Organisation/company
Business activity
Duration of service
(year to year)
1.
2.
3.
4.
5.
(b)
Educational background
Level
Institution
Year obtained
1.
2.
3.
(c)
Details of other business owned or interest owned in other business (including money services
business)
(please indicate in separate sheet if the space given is insufficient)
Name of business
Business activity
Nature of interest
(e.g. shareholder, director, partner
etc)
Amount and percentage
of shareholding
1.
2.
3.
4.
(d)
Do any of your family members (parents, siblings, spouse or children) have interests in any
money services business? if yes, please complete the following:
Name of family
Relationship with you
Name of money services
Nature of interest
(e.g. shareholder, director,
member
business
partner etc)
1.
2.
3.
4.
(e)
Source of funds (Please explain briefly on how/where you will obtain funds to finance the
acquisition of shares in the company and provide documents to support
2
(f)
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;
(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; and
(x) I have managed my affairs properly and prudently.
B:
I am*:
(i)
(ii)
representing the interest of __________________; or
not representing the interests of any person;
C:
All the information submitted above is true; and
D:
I understand that if I furnish any information required which is false, inaccurate, misleading or contains
material errors or omissions, the approval may not be granted by Bank Negara Malaysia. In the event that
the approval has been granted, it may be withdrawn.
This declaration was made before me:
(Signature of Sessions Court Judge,
Magistrate or Commissioner For Oaths)
Date:

Delete if not applicable or relevant
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(g)
Consent for disclosure (information)
As provided under item (1) of Schedule 11 made pursuant to section 134 of the Financial Services Act 2013
(FSA), item (1) of Schedule 11 made 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 authorise any
licensed business under FSA, licensed business under IFSA and prescribed institutions under DFIA where I
have account/financial liabilities to disclose to Bank Negara Malaysia, any information relating to my accounts
and affairs.
___________
(Date)
_________________
(Signature)
____________________
(Name in capital letter)
_______________
(Designation
Part III: Details of the proposed new Shareholder (Company)
Document to be enclosed:
Please tick (×) if enclosed
together with the form
Name of the company
Company’s registration
number
A copy of the shareholder
company’s registration
Date of incorporation
Locally owned:
Company’s business profile
obtained from Suruhanjaya
Syarikat Malaysia
Authorised capital
Paid-up Capital
Foreign owned:
Relevant documents from
foreign authority e.g.
Certificates of Registration
of Company, licence to
conduct MSB activities from
authorities, etc.
Address of the company
Latest audited accounts of
the company
(a)
Contact person who will act in respect of this application
Contact person
Designation
Telephone number
Fax number
E-mail address
(b)
Shareholding structure of the company
Name of shareholder
Status
(Foreign/Local)
IC/Passport no./ Company
registration no.
Amount of
shareholding
(RM)
Percentage of
shareholding
(%)
1.
2.
3.
Total
100
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(c)
Please describe business activities of the shareholder
(d)
Statutory declaration
[Declaration should be given by the individual who is applying for approval on behalf of the company
(shareholder).]
I, _________________ (name of individual), of NRIC / Passport No. ____________________, as the
____________________ (designation) of ___________________ (name of the shareholder company) do
solemnly and sincerely declare that:
A:
the company (shareholder) is not subject to the disqualifications mentioned below:
(i)
it has 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)
it has not suspended payments or compounded with its creditor whether in or outside Malaysia;
and
B:
All the information submitted above is true; and
C:
the company understands that if it furnishes any information required which is false, inaccurate,
misleading or contains material errors or omissions, the approval may not be granted by Bank Negara
Malaysia. In the event that the approval has been granted, it may be withdrawn.
This declaration was made before me:
(Signature of Sessions Court Judge,
Magistrate or Commissioner For Oaths)
Date:
(e)
Consent for disclosure (information)
As provided under item (1) of Schedule 11 made pursuant to section 134 of the Financial Services Act 2013
(FSA), item (1) of Schedule 11 made 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 authorise any licensed business under FSA, licensed business under IFSA and
prescribed institutions under DFIA where the company (shareholder) 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 individual who is applying for approval on behalf of the company
(shareholder).]
On behalf of Company (shareholder):
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______________
(Date)
_________________
(Signature)
________________________
(Name in capital letter)
______________
(Designation)
Part IV: Board Resolution of Company
(To be submitted by the existing Board of Directors of the company)
Board Resolution
We, the Board of Directors of
(Company) hereby agreed for
_______________________________(Applicant) to be the company’s new shareholder.
Board of Directors
_______________
(Signature)
Name:
____________________
(Signature)
Name:
_______________
(Signature)
Name:
____________________
(Signature)
IMPORTANT:
BANK NEGARA MALAYSIA MAY REQUEST FOR ADDITIONAL INFORMATION AS AND
WHEN REQUIRED
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