ANNEX IV
MEMBERS OF SENIOR MANAGEMENT AND THE BOARD OF THE APPLICANT
Name | Board member | Member of senior management | Date of birth | Place of birth | Role | Submitted documents | ||
CV | Proof of the absence of criminal records relating to money laundering, terrorist financing, provision of financial services or data services, acts of fraud or embezzlement, notably through an official certificate, or, where such a certificate is not available in the relevant third-country jurisdiction, a self-declaration of good repute and the authorisation to ESMA to request such information from the relevant authorities on whether that member has been convicted of a criminal offence in connection with money laundering, terrorist financing, the provision of financial services or data services or in relation to acts of fraud or embezzlement | Declaration of fitness and propriety and conflicts of interest referred to in Article 1(2), point (b), of Delegated Regulation (EU) 2025/2180 | ||||||
[First name] [Last name] | [Yes/No] | [Yes/No] | [DD/MM/YYYY] | [City, Country] | [Unique reference number] | [Unique reference number] | [Unique reference number] | |