Fit & Proper Declaration Form

1. Have you ever been engaged in or are you engaged in a civil litigation?:

2. In the past 10 years have you failed to satisfy any judgement?:

3. In the past 10 years have you made any compromises or arrangements with your creditors?:

4. In the past 10 years have you ceased trading whether as a sole trader or a partner in circumstances in which creditors did not receive full payment?:

5. In the past 10 years have you been declared bankrupt?:

6. Have you ever been subject to an order from a regulatory body?:

7. Have you ever been convicted of any criminal offence in a civil or military court in Ireland or elsewhere?:

8. Have you been refused entry to, or have you at any time ceased to be a member of any profession or vocation?:

9. Have you ever been dismissed or requested to resign from any office or employment or position of trust?:

10. Has anybody made written complaints relating to services or activities provided by your business during the past twelve months?:

11. In the last ten years have you been the director of a company which has gone into liquidation or receivership, had an administrator appointed or entered into any arrangements with its creditors either while you were a director or within three years following your ceasing to be a director?:

12. Are you aware of any allegations of negligence involving you which have been formally notified to you or to your employer’s insurers in the last 10 years?: