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CMSA Form 5

Representative application

24 questions

Section 1

Applicant details

1Applicant's name.Short text

2Other names.Short text

3Residential address.Short text

4Telephone number.Phone number

5Date of birth.Date

6Place of birth.Short text

7Number of years the applicant has resided in Tanzania.Number

8Nationality.Short text

9Occupation for which the representative licence is sought.Short text

Section 2

Principal and register details

1Full name of principal.Short text

2Full address at which the business of the principal is carried on.Long text

3Principal telephone number.Phone number

4Nature of business of the principal.Long text

5Address of the place where the applicant's register under section 52 of the Act will be kept.Long text

6Present remuneration arrangement with principal: salary, commission, or both.Select one option

7Directorship in companies in Tanzania or elsewhere.Short text

Section 3

Fitness, experience, and references

1Whether the applicant has been licensed, registered or authorised in relation to securities dealing, investment advice, or another regulated trade, business or profession.Yes / No, attach details if Yes

YesNo

Attachment required when the answer is Yes

2Whether the applicant has been refused or restricted from carrying on a trade, business or profession requiring a licence, registration or authority.Yes / No, attach details if Yes

YesNo

Attachment required when the answer is Yes

3Whether the applicant has securities exchange membership, discipline, refusal, other names used, convictions, civil judgments, refused bonds, bankruptcy, or director disqualification matters.Yes / No, attach details if Yes

YesNo

Attachment required when the answer is Yes

4Experience in performing the functions of a dealer or investment representative.Long text

5Employment and business activities of the applicant during the previous ten years.Table / multiple entries

Name / item

Details

Period / notes

Entry 1

Detailed answer

Supporting notes

6Two character referees who are not related to the applicant and have no interest in the success of the application.Table / multiple entries

Name / item

Details

Period / notes

Entry 1

Detailed answer

Supporting notes

7Interests in quoted shares of five percent or more.Table / multiple entries

Name / item

Details

Period / notes

Entry 1

Detailed answer

Supporting notes

8Additional qualifications, training, or information relevant to the application.Long text

THE UNITED REPUBLIC OF TANZANIA

CAPITAL MARKETS AND SECURITIES AUTHORITY

CMSA Form 5

Applicant details

Principal and register details

Fitness, experience, and references