Appendix II

SULIT

DECLARATION FORM BY: DIRECTOR SHAREHOLDER SENIOR OFFICER1 _________________________________________ (name of company) Instructions: (i) This form must be completed by any individual qualifying as a Director, Shareholder and Senior Officer of the company; (ii) Information in this form must be neatly and clearly written/typed; (iii) If the space allocated is insufficient, additional sheet(s) of paper may be attached. Please initial on every page including the additional sheet(s); (iv) Please provide all information required and indicate Not Applicable if the item is not relevant; and (v) Please complete 2 copies of the KPKK 11 form2 for each of the Director, Shareholder and Senior Officer. The form is available at http://www.cgso.jpm.my/files/borang_tapisan_kasar1.pdf
Full Name: Identity card no./ Passport no. : Academic and professional qualification: Contact number: Office:______________ House:________________ Mobile:_____________________ Business designation (Director/Shareholder/Senior Officer) and effective date Experience in remittance business, if any. Working experience (Please state the latest position held first) Position held/Department Main Responsibilities Organisation Country Duration

(b) Give details of all other businesses (including remittance and money changing businesses) which you have interests in: Name of business Nature of interest (e.g. Shareholder, Partner, etc) For shareholders, state the percentage shareholding

(c) Fit and Proper Questionnaire Answer the following questions Yes or No in the space provided. Please indicate details on a separate sheet of paper (if space is insuffient). Have you, as the Director/Shareholder/Senior Officer of the company been: Item (i) adjudged a bankrupt, or have suspended payments, or have been compounded by your creditors, whether within or outside Malaysia or there are bankruptcy proceedings being initiated against you at present. (ii) associated with any company in or outside Malaysia as director, shareholder or senior officer which has been wound up by a court or other authority. (iii) convicted of any offence (other than a traffic offence) within or outside Malaysia or such an offence has been compounded against you, or given judgement against you under any written law on findings in relation to: (a) Fraud; (b) Mispresentation; (c) Drug trafficking; (d) Money laundering (e) Terrorist Financing; (f) Dishonesty; or (g) Failing to keep proper records Answer Yes / No3 Details

Yes / No3

Yes / No3

(iv) convicted of an offence under any written law during Yes / No3 your tenure of office, as a director, shareholder or senior officer of any company, unless you prove that such offence was committed without your knowledge or consent and you were not in a position to prevent the offence. (v) made against you an order of detention, supervision, restricted residence, banishment or deportation, or if there has been imposed on you any form of restriction or supervision by bond or otherwise under any law relating to the prevention of crime or to restricted residence, or to banishment or immigration. Yes / No3

Note:1/ Responsible for the conduct of the business and administration 2/ Photograph of the individual must be attached to each form 3/ Delete where applicable I confirm that all the information given in this form is accurate, true and complete. I understand that if after the issuance of the written permission under the Exchange Control Act 1953 or notification under Payment Systems Act 2003, it is found that I have made false declaration in this form, Bank Negara Malaysia may prohibit me from operating the remittance business pursuant to the two Acts. I undertake to keep Bank Negara Malaysia informed of any changes in the information disclosed in this form.

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(Date)

(Signature)

(Name in Block Letters)