INFORMATION FORM



INFORMATION FORMMoney Transfer Companies______________________Date: cut-off date December 31st Name Institution FILLIN \* MERGEFORMAT I.Institution Identification Please answer completely and accurately.01Statutory Name (official company name)02Trade Name03Address04P.O. Box Number05Telephone Number06Telefax Number07Telex Number08E-mail Address09Website10Date of Incorporation11Place of Incorporation12Fiscal Year EndII.External AuditorsPlease answer completely and accurately.01Name02Address03Telephone Number04Telefax Number05E-mail Address06Auditor in Charge 07Last Audited Financial StatementsIII.Managing DirectorsPlease list the name and address of each Managing Director. Indicate whether they are a shareholder or not, their title and the date they have been appointed in this capacity. NameAddressShareholder Yes/noTitleDate01020304 0506070809IV.Members of the Supervisory BoardPlease list the name and address of each member of the Supervisory Board. If applicable, indicate whether they are a shareholder or not and the date they have been appointed in this capacity.NameAddressShareholder Yes/noDate0102030405Please submit a chart indicating the organizational structureV.ShareholdersPlease list the name and address of each Shareholder. NameAddressDate0102030405Please submit a chart indicating the group structure.VI.Offices and BranchesPlease list the address of all offices and branches, whether locally (in Cura?ao or Sint Maarten) or abroad.AddressType01020304050607VII. Affiliation and Subsidiaries If the financial institution is affiliated with other financial institutions, please list for each affiliate/subsidiary its name, country of domicile and the type (i.e. affiliate/subsidiary/joint-venture/holding company) and whether or not it is incorporated locally (in Cura?ao or Sint Maarten).NameDomicileIncorporated locally Yes/NoType01020304050607Please submit a chart indicating the legal group structure; please note this chart should be certified by an external auditorVIII. Principal Contact OfficersPositionOfficer (contact information: email address, telephone number)01General Manager02Financial Manager03Head Accounting Department04Risk Manager05Controller06Compliance OfficerIX.Service providersPlease list the address of all service providers, whether in Cura?ao or Sint Maarten.01Statutory Name (official company name)AddressTelephone NumberName Shareholder(s)Name Managing Director(s)02Statutory Name (official company name)AddressTelephone NumberName Shareholder(s)Name Managing Director(s)03Statutory Name (official company name)AddressTelephone NumberName Shareholder(s)Name Managing Director(s)X. Statement of EmploymentPlease answer completely and accurately. Indicate the number of employees for each category. The totals of rows A, B and C must be equal.CategoryTypeFull-timePart-timeABreakdown per entityLocal Officeif head officeBranchesSubsidiariesTotal ABBreakdown per areaSenior ManagementMiddle ManagementBranch ManagementOperational AreasAccounting AreasOther AreasTotal BCBreakdown per jurisdictionCura?aoSint MaartenBonaireSaba & St. EustatiusArubaOther Foreign countriesTotal CFor the purpose of this statement, only employees on the payroll are considered employees of your institution. Employees paid through an employment agency, security or cleaning office are not considered employees. Part-timers are considered employees when they work less than forty hours per week and are on the institution’s payroll.The breakdown of the number of persons employed at your institution is required for the following categories:Breakdown per entityProvide a breakdown per local office, branches and subsidiaries. The categories “branches” and “subsidiaries” need to be filled out only if the Cura?ao or Sint Maarten office is considered the “head office”.Breakdown per areaSenior management:CEO, and other key executivesMiddle management:Department and unit headsBranch management:Management of branchesOperational areas:Personnel and Human Resources, Marketing, Investments, Computer, Legal Affairs, Customer Support, Secretariat and other operational areasAccounting areas:Finance, Accounting, Bookkeeping, Administration, Auditing and other accounting areasOther areas:Technical services, Security, Cleaning, Messengers and othersBreakdown per jurisdictionEmployees employed at the institution working on the islands of the former Netherlands Antilles countries, in Aruba and in other foreign countries should be reported in this section ................
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