Independent non-executive directors who are individuals should complete
this format. This Questionnaire is not a notification or application form.
Name of the institution in connection with which this form is being completed ("the institution").
Name: FIRST__________________________ LASTNAME__________ a. Any other previous name(s) ________alias_______________
Any previous name(s) by which you have been known.
Your private Address :
Your previous private address(es) during the last 10 years
Date of Birth and Place of birth (including borough, town or city)
Name(s) and address(es) of your bankers within the last 10 years.
Your professional Qualification and year they were obtained.
Your occupation and employment now and during the last 10 years, including the name of the employer in each case, the nature of the business, the position held and relevant dates.
Of what bodies corporate (other than the institution) are you now a director?. Give relevant dates and, if you are a controller of any such bodies corporate, indicate in what sense.
Are you a significant shareholder of any body corporate (other than the institution), which is now authorised or has applied for authorisation under, Banking Act ? If so, give particulars.
Of what bodies corporate other than the institution and those listed in answer to question 11 have you been a director, at any time during the last 10 years ? Give relevant dates.
Do any of the bodies corporate listed in the answer to question 10 to 12 maintain a business relationship with the institution? If so, give particulars
Does any institution with which you are, or have been, associated as a director, hold, or has it ever held or applied for, a licence or equivalent authorisation to carry on any business activity? If so, give particulars. If any such application was refused, or was withdrawn after it was made or any authorisation revoked, give particulars.
Have you at any time been convicted of any offences? If so, give particulars or the court by which you were convicted, the offence and the penalty imposed and the date of conviction.
Have you been censured, disciplined, warned as to future conduct, or publicly criticised by, or made the subject of a court order at the instigation of, any regulatory authority (including but not limited to the Secretary of State for Trade and Industry, a recognised self-regulating organisation and the Takeover Panel.) or any professional body to which you belong or belonged, or have you ever held a practicing certificate subject to conditions? If so, give particulars.
Have you, or has any body corporate, partnership or unincorporated institution with which you are, or have been, associated as a director, been the subject of an investigation or at the instigation of a government department or agency, professional association or other regulatory body ? If so, give particulars.
Have you been dismissed from any office or employment, subject to disciplinary proceedings by your employer or barred from entry to any profession or occupation ? If so, give particulars
Have you incurred a judgement debt under an order of a court or made any compromise arrangement with your creditors within last 10 years ? If so, give particulars.
Have you been adjudicated bankrupt by a court or has a bankruptcy petition ever been served on you? If so, give particulars.
Have you, in connection with the formation or management of any body corporate, partnership or unincorporated institution, been adjudged by a court, civilly liable for any fraud, misfeasance or other misconduct by you towards such a body or company or towards any members thereof? If so, give particulars.
Has any body corporate, partnership or unincorporated institution with which you were associated as a director been wound up, made subject to any administration order, otherwise made any compromise or arrangement with its creditors or ceased trading either which you are were associated with it or within one year after you cease to be associated with it or has anything analogous to any of these events occurred under the laws of any other jurisdiction ? If so, give particulars.
Have you been concerned with the management or conduct of affairs of any institution which, by reasons of any matter relating to a time when you were so concerned, has been censured, warned as to future conduct, disciplined or publicly criticised by, or made the subject to a court order at the instigation of, any regulatory authority ? If so, give particulars.
In carrying out your duties will you be acting on the directions or instructions of any other individual or institution ? If so, give particulars
Do you, in your private capacity, or does any related party, under taken business with the institution? If so, give particulars.
How many shares in the institution ( or another institution of which the institution is a subsidiary undertaking ) are registered in your name or the name of a related party, If applicable, give name(s) in which registered and class of shares.
In how many shares in the institution or another institution of which the institution is a subsidiary undertaking (not being registered in your name or that of a related party, are you or any related party beneficially interested?
Do you, or does any related party, hold any shares in the institutions as trustee or nominee? if so, give particulars.
Are any of the shares mentioned in answer to question 31 to 33 equitably or legally charged or pledged to any party ? if so, give particulars.
What proportion of the voting power at any general meting of the institution (or of another institution of which it is a subsidiary undertaking ) are you or any related party, entitled to exercise or control exercise of ?
If the exercise of the voting power any general meeting of the institution ( or another institution of which it is a subsidiary undertaking) is or may be controlled by one or more associates ( As per BR Act, 1949 and Present RBI instructions) of you or of any related party, give the proportion of the voting power so controlled in each case and the identity of each associate.
Are you presently, or do you expect to be, engaged in any litigation other than in a professional capacity ? If so, give particulars.
Note : The questionnaire is on the lines of the one used by the FSA of UK, modified keeping in view of our requirements, could be used as a model.
