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التوقيع Signature

1

مالءمح الومىذج

Fit and Proper Form

V1.1

اششخ اع اشخض

Name of Nominated Person

اخ١بس ثػغ دذد) اظت امزشح

(ثجبج ػالخ

Proposed Position

(select by entering the mark

next to selected option)

ػؼ جظ اإلداسح

Board Member

اروش اع اجخ: ،جظ اإلداسحاجثمخ جب ا ف ئدذػؼ

Member of Board Committee (specify name of committee)

، اروش اع اظت: ف اإلداسح اؼ١ب ػؼ

Member of Senior Management (specify title of position)

اإعغخ اب١خاع

Name of Financial Institution

ثػغ اخ١بس دذد) اإعغخ اب١خ ع

(ثجبج ػالخ

Type of Financial Institution

(select by entering the mark

next to selected option)

ثه

Bank

، أ ششوخ ششوبد ا اذشح ازؼمخ ثبزأ١ششوخ رأ١ /أ ئػبدح رأ١

Insurance and/or Reinsurance Company or Insurance-related Service

Provider

ششوخ ر٠

Finance Company

طشاف

Money Exchanger

اروش: غ١ش ره،

Other (specify)


2

Instructions ذؼليماخ

1. The following words and phrases, wherever they

appear in this Form, shall have the corresponding

meanings, unless the context requires otherwise:

زا ارج،أ٠ب سدد ف ،٠مظذ ثبألفبظ اؼجبساد ا٢ر١خ (1

اؼب اج١خ أب و ب، ب ٠مزغ اغ١بق خالف ره:

Kingdom: the Kingdom of Saudi Arabia. :اىخ اؼشث١خ اغؼد٠خ.المملكح

SAMA: the Saudi Arabian Monetary Agency إعغخ امذ اؼشث اغؼد. :المؤسسح

Applicable Laws, Regulations, and

Instructions: the laws, regulations, rules, and

instructions to which the Financial Institution

and/or the Proposed Position is subject, including

without limitation the following:

األظخ اائخ :ذاخ الؼالقحوالرؼليماخ األوظمح واللىائح

/أ ازؼ١بد از رخؼغ ب اإعغخ اب١خاماػذ

رش ػ ج اخظص ، ثذغت اذبي، اظت امزشح

د دظش ا٢ر:

“Banking Control Law, and related rules and

instructions,” if the Financial Institution is a

bank or a branch of a foreign bank.

ظب شالجخ اجن اماػذ ازؼ١بد راد اؼاللخ، ئرا

وبذ اإعغخ اب١خ ثىب أ فشػب جه أجج.

“Law on Supervision of Cooperative Insurance

Companies, its Implementing Regulations,

other related regulations, rules, and

instructions,” if the Financial Institution is an

insurance and/or reinsurance company or an

insurance-related service provider.

،ظب شالجخ ششوبد ازأ١ ازؼب، الئذز ازف١ز٠خ

خ، ئرا وبذ اإعغخ اائخ اماػذ ازؼ١بد راد اؼالل

ششوبد ششوخ أ اب١خ ششوخ رأ١ /أ ئػبدح رأ١

.ثبزأ١ ازؼمخ اذشح ا

“Law on Supervision of Finance Companies,

its Implementing Regulations, and other

related rules and instructions,” if the Financial

Institution is a finance company.

ظب شالجخ ششوبد از٠، الئذز ازف١ز٠خ، اماػذ

ازؼ١بد راد اؼاللخ، ئرا وبذ اإعغخ اب١خ ششوخ

ر٠.

“Rules Governing of Money Exchange

Activities, and other related rules and

instructions,” if the Financial Institution is a

money exchanger.

اماػذ اظشافخ، أػبي ضاخ اظخ اماػذ

.طشافب اب١خ اإعغخ وبذ ئرا اؼاللخ، راد ازؼ١بد

Form: the Fit and Proper Form. االءخ. رج :الىمىذج

Nominated Person: the person whose name is

indicated on the first page of this Form and who is

a candidate for the Proposed Position in the

Financial Institution.

اػخ اع ف اظفذخ األ اشخض :المسشح الشخص

.إعغخ اب١خا ف امزشح ظت اششخ زا ارج

Financial Institution: the institution whose name

is indicated on the first page of this Form, and in

which the Nominated Person will have the

Proposed Position.

اػخ اعب ف اظفذخ اإعغخ اب١خ :المؤسسح الماليح

اششخ اشخضاز عف ٠شرجؾ ثب األ زا ارج

. ظت امزشح


3

Proposed Position: membership of board, or one

of its committees, holding a senior management

position.

اجب اجثمخ اإلداسح أ ئدذ ػؼ٠خ جظ :المقرسح المىصة

ف اإعغخ اؼ١بأ ر ظت ف اإلداسح جظ اإلداسح

.اب١خ

Related Party: husband, wife, father, mother,

grandfathers and grandmothers, and their

ancestors upward; sons and daughters, grandsons

and granddaughters, and their descendants

downward; and brothers and sisters, or those with

whom the Nominated Person shares a business

relationship that could impact his/her

independence.

األة األ اجذ اجذح ئ ضجخا ضجا : صلح ذو طسف

ضا، اإلخا ئػ، األثبء اجبد أثبئ ثبر

األخاد، أ رشثط ػاللخ رجبس٠خ شأب ازأث١ش ػ

اعزمال١خ اششخ.

2. The information provided by the Nominated

Person in this Form must be correct, accurate,

precise, and complete and does not contain any

false, incorrect or misleading information, nor

conceal any material information that should be

disclosed and singed by the Nominated Person.

SAMA may exclude any violated nomination

without any responsibility.

٠جت أ رى اؼبد امذخ لج اششخ ف زا (2

ارج طذ١ذخ دل١مخ وبخ خب١خ أ ؼبد صائفخ أ

خبؽئخ أ ظخ أ ال رخف ؼبد جش٠خ وب ٠جت

اإلفظبح ػب أ ٠لغ ػ١ب إعغخ اعزجؼبد أ رشش١خ

.خ٠خبف ره د أد غإ١

3. A copy of the Nominated Person’s Saudi national

ID (For non-Saudi: passport, visa, and Iqama,

where applicable) shall be attached with this

Form.

، (غؼد١٠) اؽ١خ ا٠خ جطبلخ طسح غ ارج ٠شفك (3

غ١ش) ثذغت رافشب إللبخا ازأش١شح اغفش جاص طس

.(اغؼد١٠

4. The Financial Institution shall attest this Form in

the designated space.

اىب ف ارج زا ػ اب١خ اإعغخ رظبدق أ ٠جت (4

.اخظض

5. This Form shall be read in conjunction with the

Requirements for Appointments to Senior

Positions in Financial Institutions Supervised by

SAMA.

ف ازؼ١١ زطجبدأ رمزش لشاءح زا ارج غ ٠جت (5

إلششاف اخبػؼخ اب١خ اإعغبد ف ام١بد٠خ ابطت

.اإعغخ

6. If extra space is required to answer any question,

then attach the answers to this Form, making a

reference to question(s) number and its text; Each

attachment must be signed by the Nominated

Person.

األعئخ، أدذ ػ إلجبثخ اخظظخ اغبدخ وفب٠خ ػذ دبي ف (6

اغإاي سل رذذ٠ذ غ خبسج١خ سلخ ف اإلجبثخ ئسفبق ف١جغ

.اششخ اشخض اشفمخ اسلخ رل١غ ظ

7. This Form shall not be modified in any way. 7) األشىبي شى ثأ ارج زا رؼذ٠ ٠جص ال.


4

المؼلىماخ الشخصيح .1

1. Personal Information

االع اىب

Full Name

أ أعبء أخش عبثمخ أ ٠ؼشف ثب اشخض

اششخ

Any other different or previous name(s)

of the Nominated Person

اجغ١خ أ اجغ١بد

Nationality(ies)

سل اجاص دخ )سل ا٠خ اؽ١خ غؼد١٠

(اإلطذاس غ١ش اغؼد١٠National ID number for Saudis (Passport

number and issuing country for non-

Saudis)

اغؼد١٠ غ١ش ظذسب ربس٠خب ازأش١شح سل

Visa number, date and place of

issuance (for non-Saudis)

ربس٠خ ا١الد

Date of birth

ذ٠خ دخ ا١الد

City and country of birth

ػا اإللبخ اذب١خ

Present Residential Address

ػا اإللبخ اذائخ )ئرا اخزف ػ ػا اإللبخ

اذب(

Permanent Residential Address

(if different from Present Address)

سل ابرف اجاي

Mobile phone number

سل برف ثذ٠

Alternative phone number

اجش٠ذ اإلىزش

Email address

اؼا اجش٠ذ

Mailing Address

أذ م١ ف اىخ ثظفخ دائخ؟

Are you a permanent resident in the

Kingdom?

Yes ؼ

No ال


5

2. Provide details of all academic degrees you

have completed.

اذكس ذفاصيل جميغ المؤهالخ الؼلميح الري حصلد ػليها. .2

اذخاجخ عخ اذظي ػ اذسجخ اذسجخ اؼ١خ ازخظض

Year of Completion Institution and Country Major Degree

3. Provide details of all professional qualifications

you have completed.

. اذكس ذفاصيل جميغ المؤهالخ المهىيح الري حصلد ػليها .3

اإ ا ازخظض اجخ اذخ عخ اذظي ػ اإ

Year of Completion Institution and Country Major Qualification

4. List all the companies in which you are

currently, or have been in the past ten years, a

board member or manager.

جاذكس جميغ الشسكاخ الري ذشغلل ييهغا مىصغة ػمغى مإلغر از .4

يسا خغال أو مديسا أو شللد ييها مىصة ػمى مإلر ازج أو مد

السىىاخ الؼشس الماضيح.

اظتأعجبة رشن اششوخ اع اظت ربس٠خ اجذا٠خ ربس٠خ اب٠خ

Reason(s) for

Leaving Position

End Date Start Date Position Name of Company


6

اظتأعجبة رشن اششوخ اع اظت ربس٠خ اجذا٠خ ربس٠خ اب٠خ

Reason(s) for

Leaving Position

End Date Start Date Position Name of Company

5. List all the companies in which you currently

own shares.

اذكس جميغ الشسكاخ الري ذملك ييها أسهما. .5

اع اششوخ ػا اششوخ ؽج١ؼخ شبؽ اششوخ غجخ اى١خ

Ownership

Percentage

Nature of Business Company’s Address Name of Company


7

6. Provide details of all shares you are holding in

this Financial Institution that are registered in

your name or in the name of a Related Party.

اذكس ذفاصيل األسهم الري ذملكها يغي المؤسسغح الماليغح تاسغمك أو .6

.صلح تكتاسم طسف ذو

األع ث اغجخ االع ػذد األع غجخ اى١خ

Ownership

Percentage

Number of Shares Name under which Shares are Registered

7. Provide details of all shares in this Financial

Institution that concern you or concern a

Related Party from a beneficial point of view

but are NOT registered in your name or in the

name of Related Party?

( صغلح تغكاذكس ذفاصغيل األسغهم يريغس المملىكغح لغك أو لوغسف ذو .7

صغلح تغك مغه يي المؤسسح الماليح والرغي ذهمغك أو ذهغم طغسف لغ

حيث االورفاع.

األع ث اغجخ االع ػذد األع غجخ اى١خ

Ownership

Percentage

Number of Shares Name under which Shares are Registered

8. Do you or any Related Party hold any shares in

this Financial Institution as a trustee or

attorney in fact?

المؤسسغح هل ذملك أو يملغك أ طغسف ذو صغلح تغك أ أسغهم يغي .8

كىصي أو وكيل؟الماليح

No ال

Yes ؼ

If the answer is “Yes”, provide details: :ئرا وبذ اإلجبثخ ثؼ، اروش ازفبط١


8

9. Are any of the shares mentioned in answers to

questions (6), (7), and (8) related to the account

of another party or legally pledged?

( 8( وي7( وي6هغغل أ مغغه األسغغهم المغغركىزج يغغي جاتغغح األسغغ لح ي .9

لحساب طسف ما أو مسهىوح قاوىويا؟ذؼى

No ال

Yes ؼ


10. Are you a shareholder, board member, or

manager in any other company that is licensed

or has applied for a license to engage in an

activity that is governed by Banking Control

Law, Law on Supervision of Cooperative

Insurance Companies, Law on Supervision of

Financing Companies, Capital Market law, or

Rules Governing of Money Exchange

Activities?

مغسخص شسكح يي مديس أو ازج مإلر ػمى أو مساهم أود هل .11

الثىغى مساقثغح لىظغا يخمغ وشاط لممازسح ذسخيصا طلثد أو لها

شغسكاخ مساقثغحأو وظغا الرؼغاووي الرأميه شسكاخ مساقثح وظا أو

لمزاولغغح المىظمغغح القىاػغغدأو الماليغغح السغغى وظغغا أو الرمىيغغل

؟ الصسايح أػما

No ال

Yes ؼ



9

11. Answer the following questions by entering a

tick mark ( ) in the appropriate column.

اإلجاتح الري خاوح( يي يأجة ػلى األس لح اآلذيح تىضغ ػالمح .11

يرم اخريازها.

اإلجبثخ

Answer

األعئخ

Questions

اشل

Ref.

ال

No

ؼ

Yes

الحسىح األماوح والىزاهح والسمؼح

Honesty, Integrity and Good Reputation

1

؟داخ اىخ أ خبسجبعاء ،جش٠خ أ عجك أ دى ػ١ه ثبسرىبة

Have you ever been convicted of any offence, whether in the Kingdom or elsewhere?

1.1

لل لجلل أ عللطخ زمللذد ػللب أ ثشللى عللش، أ دللزسد أ جلل لله الل أ ازأ١للت، أ ا لل عللجك لله، ػللب

١لخ أ جلخ أخلش بثلخ، أ أخلز ػ١له رؼلذ ثؼلذ ام١لب ثؼل ؼل١، أ ولذ خبػلؼب ذىل ئششاف١خ أ ١ئخ

؟داخ اىخ أ خبسجبدػبء جخ ئششاف١خ أ ١ئخ ١خ أ جخ أخش بثخ، عاء اػ لؼبئ ثبء

Have you ever been, publicly or secretly, warned, censured, reprimanded, or publicly

criticized by any supervisory authority, professional body, or similar bodies, or have

signed an undertaking not to conduct certain work, or have been the subject of a court

order at the instigation of such body, whether in the Kingdom or elsewhere?

1.2

أ لخ رزطلت رشخ١ظلب أ رغلج١ال أ لب شلبؽأ ؼذ دك بسعخ رجلبسح أ ػل رجلبس عجك أ

؟داخ اىخ أ خبسجبعاء ، بسعزه زه اذكرف٠ؼب أ ل١ذد

Have you ever been denied the right or restricted in your right to carry on any trade,

business, financial activity, or profession that requires a specific license, registration or

other authorization, whether in the Kingdom or elsewhere?

1.3

أ عجك أ وذ غب أ ػؼ جظ ئداسح أ ذ٠ش ف شأح ؼذ دك بسعخ رجبسح أ ػ رجلبس

، أ فل شلأح سفلغ أ بسعلزب لزه اذلكأ خ رزطت رشخ١ظب أ رغج١ال أ رف٠ؼلب أ ل١لذد شبؽ ب

أ جلخ جلخ ئشلشاف١خ أ ١ئلخ ١لخ ألف أ أ أ عذت أ أغل رشخ١ظلب أ رغلج١ب أ رف٠ؼلب ل لجل

؟داخ اىخ أ خبسجبعاء بثخ، أخش

Have you ever been a shareholder, board member, or manager of a business that has

been denied the right or restricted in its right to carry on any trade, business, financial

activity, or profession that requires a specific license, registration or other authorization,

or of a business whose license, registration or other authorization has been suspended,

stopped, terminated, withdrawn, or revoked by any supervisory authority, professional

body, or similar bodies, whether in the Kingdom or elsewhere?

1.4

لل عللجك أ لللذذ ؼللبد خبؽئللخ أ ؼللخ إعغللخ امللذ اؼشثلل اغللؼد أ أ جللخ ئشللشاف١خ أ دى١للخ

فل أ رؼبل لغ إعغلخ املذ اؼشثل اغلؼد أ أ أ أثذ٠ذ ػذ رؼب، أ اىخ أ خبسجبداخ أخش

؟داخ اىخ أ خبسجبجخ ئششاف١خ أ دى١خ عاء

Have you ever provided false or misleading information to SAMA or any other

supervisory authority or government body, or been uncooperative in any dealings with

SAMA or any other supervisory authority or government body, whether in the

Kingdom or elsewhere?

1.5


11

اإلجبثخ

Answer

األعئخ

Questions

اشل

Ref.

ال

No

ؼ

Yes

أ علجك أ خؼلؼذ ،جش٠خ جبئ١لخأ أدذ ثبسرىبة االرب ف شأ جش٠خ جبئ١خ، أا ج ه عجك أ

؟داخ اىخ أ خبسجبعاء ،جشاءاد رأد٠ج١خجبئ أ ئرذم١ك أل

Have you ever been censured, prosecuted, or convicted of a criminal offence, or been

the subject of any criminal investigation or disciplinary proceedings, whether in the

Kingdom or elsewhere?

1.6

عجك أ رؼشػلذ العلزجاة أ رذم١لك أ ئجلشاء رلأد٠ج ل لجل أ جلخ ئداس٠لخ، دى١لخ أ غ١لش دى١لخ،

؟داخ اىخ أ خبسجبعاء

Have you ever been the subject of any interrogation, investigations, or disciplinary

proceedings by any government or non-government entity, whether in the Kingdom or

elsewhere?

1.7

أ ظب شالجخ اجن، أ ظب اغق اب١خ، أ ظب شالجخ ششوبد ظب جضائ، عجك أ أدذ ثخبفخ أ

أ أ أ اماػذ اظخ ضاخ أػلبي اظلشافخ ، أ ظب شالجخ ششوبد از٠، أ ائذب،ازأ١ ازؼب

؟داخ اىخ أ خبسجبعاء أظخ أ ائخ أخش،

Have you ever been convicted of a violation of any criminal law, Banking Control

Law, Capital Market Law, Law on Supervision of Cooperative Insurance Companies,

Law on Supervision of Finance Companies, the regulations of those laws, Rules

Governing of Money Exchange Activities or any other laws or regulations, whether in

the Kingdom or elsewhere?

1.8

الزثلبي أل أظلخ أ لائخ أ رؼ١لبد، أ علجك له رملذ٠ اؼل أل شلخض أثذ٠ذ ػذ االعزؼذاد عجك أ

داخ عاء آخش ف خبفخ أدىب أ أظخ أ ائخ أ رؼ١بد ثأ شى األشىبي أ رذش٠ؼ ػ خبفزب،

؟اىخ أ خبسجب

Have you ever demonstrated unwillingness to comply with any laws, regulations, or

instructions, or in any way helped or abetted another person in breach of any laws,

regulations, or instructions, whether in the Kingdom or elsewhere?

1.9

داخل علاء ألظلخ الائخ ازؼ١لبد، عجك أ أدذ ثبسرىبة جش٠خ خخ ثبشلشف أ األبلخ أ خبفلخ


Have you ever been convicted of an offence involving moral dishonesty or breach of

trust or contravention of laws, regulations and instructions, whether in the Kingdom or

elsewhere?

1.10

ف زذم١ك الشزجب رؼشػذ ، أ ثبسعزبأ غ١ش شخض بسعخ أ شبؽبد غ١ش ظشحثأ أدذ عجك

؟داخ اىخ أ خبسجبعاء ،أ غ١ش شخض ثب شبؽبد غ١ش ظشحبسعزه أ

Have you ever been convicted of practicing any unauthorized or unlicensed activities

or been investigated for the possible carrying out of unauthorized or unlicensed

activities, whether in the Kingdom or elsewhere?

1.11

االعلزثبس بألػلبي ازجبس٠لخ أ ثرغ٠خ ف ئجشاءاد ذ١خ شرجطلخ لشاسلؼبئ أ أ طذس ثذمه دى عجك

؟داخ اىخ أ خبسجبعاء ، اب١خ األخش أ عء عن أ اخزالط أاياألػبي أ

Have you ever been subject to a judicial order or settlement order under civil

proceedings in relation to commercial, investment, or other financial business,

1.12


11

اإلجبثخ

Answer

األعئخ

Questions

اشل

Ref.

ال

No

ؼ

Yes

misconduct or misappropriation of funds, whether in the Kingdom or elsewhere?

خ ب١ل درؼلبالأ ادائغ، أ رمغ١ش لب زؼك ثبألػبي اظشف١خ، أ شبؽثأ وذ شرجطب عجك أ

؟داخ اىخ أ خبسجبعاء أخش، أ رجبس٠خ

Have you ever been associated with any illegal activity concerning banking business,

deposit taking, or other financial or business dealing, whether in the Kingdom or

elsewhere?

1.13

؟داخ اىخ أ خبسجبعاء عجك أ اعزمذ ظ١فخ أ ظت أثبء خؼػه زذم١ك،

Have you ever resigned from any role or position whilst under investigation, whether

in the Kingdom or elsewhere?

1.14

أ لللشاس لل جللخ افظلل فلل دىلل لؼللبئ لل اذللبو اؼبللخ أ د٠للا اظللب،لل عللجك أ طللذس فلل دملله

جب افظ ف ابصػبد اخبفلبد أدذ ، أابصػبد اظشف١خ جخأ جن خبفبد أدىب ظب شالجخ ا

أ أ أ جخ افظ ف بصػبد األساق اب١خ، ف اخبفبد ابصػبد از١٠خ، افظ خازأ١١خ، أ ج

؟داخ اىخ أ خبسجبعاء ، أخش لؼبئ١خ أ شج لؼبئ١خجب

Are there any judgments or decision(s) issued against you by general courts, Board of

Grievances, the Committee for Resolutions of Banking Control Law Violations, the

Committee of Banking Disputes, Committees for Resolutions of Insurance Disputes

and Violations, or Committee for Resolutions of Finance Violations and Disputes, or

Committee for Resolutions of Securities Disputes, or other judicial or semi-judicial

committees, whether in the Kingdom or elsewhere?

1.15

شلأب رغ١١لش أ ل ئجبثبرله ػل أ ل أ لبئغ أذ ػ ػ ثأ ئجشاءاد لبئخ لذ رإد ئ ظشف

؟داخ اىخ أ خبسجبعاء ، األعئخ اغبثمخ أ أ ذ أ شخض ١خ جذء ثاجشاءاد بثخ

Are you aware of any circumstances or pending proceedings that may lead to situations

that could alter any of your answers to the previous questions, or of anybody's intention

to begin such proceedings, whether in the Kingdom or elsewhere?

1.16

القدزج والكفاءج

Competence and Capability

2

ػل رؼ١١لله فلل أ أ لل رافللك بثللخ أ اػزشػلذ أ جلخ أخللشجللخ ئشلشاف١خ أ ١ئللخ ١للخ ل عللجك أل

؟اىخ أ خبسجب داخعاء ظ١فخ أ ظت،

Has any supervisory authority, professional body, or similar bodies, ever objected or

refused to provide non-objection on your appointment to any role or position, whether

in the Kingdom or elsewhere?

2.1

عجك أ جشدد أ١خ اؼ وذ٠ش أ جشدد أ١زه ؼ ثظفخ ئداس٠خ، أ ذ١ذ اؼل ولذ٠ش أ

؟داخ اىخ أ خبسجبعاء ؼ ثظفخ ئداس٠خ،ا

Have you ever been declared incompetent as a director or in any managerial capacity,

or disqualified from acting in such capacity, whether in the Kingdom or elsewhere?

2.2

داخل علاء عجك أ فظذ أ ؽت ه االعزمبخ ل ظ١فلخ و١ل أ طل أ أ ظ١فلخ أ ظلت آخلش،


Have you ever been dismissed, or requested to resign from a position of attorney,

2.3


12

اإلجبثخ

Answer

األعئخ

Questions

اشل

Ref.

ال

No

ؼ

Yes

trustee, or any other role or position, whether in the Kingdom or elsewhere?

اظلت م١لب ثبله فل االصلخ اؼ١لخ البساد اؼشفلخ اخجلشح لإالد اؼ١لخ ا ٠مظله أ ل

ػ أو ج؟ امزشح

Do you lack any of the educational qualification, experience, relevant skills, and

knowledge, required to perform your duties in the Proposed Position?

2.4

اظلت امزلشحثزلف١ش اللذ اجلذ الالص زأد٠لخ دسن فل ػل ازضالهعلجب به ب ٠ى أ ٠لإثش

ثشى فؼبي؟

Are there any potential impediments to your commitment, in terms of time and effort,

to perform your role in the Proposed Position effectively?

2.5

لمالءج الماليحا

Financial Soundness

3

اجلن أ ازغل١الد االئزب١لخ، رجلبثلب فل رله املشع ،افلبء ثبزضابرله اب١لخ أ ػجضد ػل عجك

؟داخ اىخ أ خبسجبعاء ،اعزذمبلب، دبي ششوبد از٠

Have you ever been unable to fulfill your financial obligations, including loans or

credit facilities, toward banks or financing companies, as and when they fell due,

whether in the Kingdom or elsewhere?

3.1

ؼبلخ رفؼل١١خ ل دائ١له، أ دخلذ فل ظلبذخ أ رشر١جلبد ؼ١لخ لغ دائ١له أأ رم١لذ ئػفلبءاد علجك

؟داخ اىخ أ خبسجبعاء زغ٠خ ازضابره اب١خ،

Have you ever availed any financial relief or preferential terms from your creditors or

entered into a compromise or scheme of arrangement with your creditors to settle your

debt obligations, whether in the Kingdom or elsewhere?

3.2

أ لشاس طبدس جخ ذىخ طبدس دى ثجت اذفغ اجت غزذك ثذ٠ افبء ػ ػجضد أ عجك

دائ١ه؟ غ أ رغ٠خ ظبذخ رشر١ت أ أثشذ أ عجك أ داخ اىخ أ خبسجب لؼبئ١خ خزظخ عاءHave you ever failed to settle a debt due and payable under a judgment issued by a

court or a competent judicial committee in the Kingdom or elsewhere, or have you ever

made any compromise arrangement or settlement with your creditors?

3.3

أ دخلذ فل أ دىل ػ١له ثلبإلفالط لذذ ػش٠ؼخ ئفلالط فل دمله رمذذ ثطت ئػال ئفالعه أ عجك أ

؟داخ اىخ أ خبسجبعاء ،شبثخ ئجشاءادأ رغ٠خ غ اذائ١ أ خؼؼذ أل

Have you ever been the subject of a bankruptcy petition, or adjudicated a bankrupt, or

entered into a general settlement with any creditor, or been subject to any other similar

process, whether in the Kingdom or elsewhere?

3.4

عجك أ وذ غب أ ػؼ جظ ئداسح أ ذ٠ش فل شلأح رؼشػلذ إلفلالط أ ازظلف١خ أ اػلغ رذلذ

خ ف الذ از وبذ ه ػاللخ ثز اشلأح أ خلالي ػلب ادلذ ل ازلبء رله ازظف١خ أ اػغ رذذ اطب٠

؟داخ اىخ أ خبسجبعاء ، خؼاللا

Have you ever been a shareholder, board member, or manager of a business that has

gone into bankruptcy, liquidation, or placed under trusteeship or administration during

the period when you were a shareholder, board member, or manager of the business or

within one year thereafter, whether in the Kingdom or elsewhere?

3.5


13

اإلجبثخ

Answer

األعئخ

Questions

اشل

Ref.

ال

No

ؼ

Yes

االسرقالليح

Independence

4

رطل١خ ل شلخض أ رج١ل أ رؼ١لبد أ ثلبء ػل فل اإعغلخ اب١لخ امزلشح ظلت ولب رششل١ذه

شأح ؼ١خ؟

Was your designation for the Proposed Position with the Financial Institution based on

the direction, instruction, or recommendation of an individual or institution?

4.1

؟اظت امزشح عزؼ فك رج١ أ رؼ١بد أ شخض أ شأح خالي ل١به ثبه ف

Will you be acting on the directions or instructions of any individual or institution in

carrying out your duties in the Proposed Position?

4.2

ه؟ب أ ذساءب ؽشف ر طخ ثأ أػؼبء جظ ئداسر اإعغخ اب١خغب أ ٠ؼذ

Are any of the Financial Institution’s shareholders, board members, or managers

considered a Related Party to you?

4.3

)ثلل اغللبخ فلل ى١للخ اإعغللخ اإعغللخ اب١للخللغ اظللت امزللشحلل عللف رللشرجؾ ثللأ ػاللللخ خللالف

أخش(؟ أ ب١خ اب١خ، أ اشبسوخ ف ػؼ٠خ جظ ئداسرب أ ئداسرب اؼ١ب أ أ ػاللخ رجبس٠خ

Will you have any other relationship (e.g. shareholding, board membership,

management membership, or commercial or financial relationship) with the Financial

Institution beyond the Proposed Position?

4.4

رب أ رملللذ٠ بفللل شالجلللخ اإعغلللخ اب١لللخ أ شاجؼلللخ دغلللبث ،فللل أ للللذ للل األللللبد ،أ ػلللذللل علللجك

ثظفزه اشخظ١خ أ خالي و١ب ره ف١ل أ رشلبسن فل ػؼل٠خ ، عاء باالعزشبساد أ أ خذبد أخش

ف١؟ذ٠شا سر أ رؼ جظ ئداHave you ever supervised or audited the Financial Institution, or provided consultations or

other services to the Financial Institution, either in your personal capacity or through an

entity in which you are a shareholder, a board member, or a manager?

4.5

ذ أ اشلشوبد أ اإعغلبد ازل رغلب فل ى١زلب أ رشلبسن فل ػؼل٠خ جلظ ئداسرلب أ رزل

غ اإعغخ اب١خ؟ أ ب ظت ذ٠ش ف١ب أ شبؽ رجبس

Do any of the companies or establishments in which you are currently a shareholder,

board member, or manager conduct any type of business or financial activities with the

Financial Institution?

4.6

اإعغخ اب١خ ف شبؽ شبثبث أ أذ غب أ ػؼ جظ ئداسح أ ذ٠ش ف إعغخ ربسط شبؽ

اىخ؟

Are you a shareholder, board member, or manager of an institution in the Kingdom that

conducts same activity(ies) as Financial Institution or similar activity(ies)?

4.7

رؼلبسع فل رإد ئ أخش لذ ظشف أ أ ظ١ف١خ ازضابدأ أ ب١خ ظبخ رجبس٠خ ثأ أذ ػ ػ

؟اظت امزشحف ثأ شى وب ػ اعزمال١زه لذسره ػ أداء اججبره اظبخ أ ٠ى أ رإثش

Are you aware of any business interests, financial interests, employment obligations, or

any other situations which might give rise to conflict of interest or which could in any

way impair your independence and ability to discharge your duties effectively in the

Proposed Position?

4.8


14

If any of the answers to the questions above is

“Yes”, then provide detailed answers for all

questions to which you responded “Yes” in the

following space by making a reference to the

question concerned.

ذا كاود جاترك ػلى أ مه األس لح الساتقح تـ "وؼغم" ييإغة زاج

جاتح ذفصيليح مغ تيان زقم السؤا لإميغ األسغ لح الرغي أجثغد ػليهغا

الثيان اآلذي:تـ "وؼم" يي

اإلجبثبد ازفظ١١خ

Detailed Answers

اشل

Ref.

Note: if extra space is required to answer any

question, then attach the answers to this Form, making

a reference to question(s) number and its text. Each

attachment must be signed by the Nominated Person.

أدذ ػ إلجبثخ اخظظخ ف دبي ػذ وفب٠خ اغبدخذظخ:

اغإاي سل رذذ٠ذ غ خبسج١خ سلخ ف اإلجبثخ ئسفبق ف١جغ األعئخ،

.اششخ اشخض فمخااش اسلخ رل١غ ظ


15

12. Are there any other material facts that were not

provided in this Form that may affect SAMA’s

decision regarding your appointment to

Proposed Position with the Financial

Institution?

الىمغغىذج هغغرا ػليهغغا يشغغرمل لغغم جىهسيغغح مؼلىمغغاخ أ هىغغا هغغل .12

ػغد المماوؼغح ػلغى شغأن يغي المؤسسح قساز ػلى ذؤثس أن ويمكه

مغ المؤسسح الماليح؟ المىصة المقرسح ذىليك

No ال

Yes ؼ


16

Acknowledgement قساز وذؼهد

I hereby acknowledge that I have read all of the

Applicable Laws, Regulations, and Instructions. I am

aware that it is a sanctionable offence under the

provisions of Applicable Laws, Regulations, and

Instructions to knowingly or recklessly provide

SAMA or any other natural or legal person any

information that is false or misleading in connection

with the conduct of business or financial activities in

Saudi Arabia.

د راازؼ١للبد األظللخ اللائخ ج١للغ لللشأد ألل للزا ثجللت ألللش

إعغلخ ؼلخ أ طذ١ذخ غ١ش ؼبد أ رمذ٠ أ أػ ،اؼاللخ

األػلبي بسعلخ دلي اػزجبس أ ؽج١ؼ شخض أل أ جخ أل أ

اجلبالح ؼذ أ ػ ػ ره وبأ عاء اىخ، ف ازجبس٠خاب١خ أ

األظللخ أدىللب ثجللت اؼمثللخ رغللزجت خبفللخ ٠ؼزجللش ازمظلل١ش، أ

.اائخ راد اؼاللخ

I certify that the information given in the answers to

this Form are complete, accurate, and precise, and that

there is no other relevant material information which

is not disclosed in this Form or attachments to this

Form. I undertake that I will provide SAMA with any

information or documents SAMA may request to

verify any of the information provided in this Form

within (10) business days from the date on which

SAMA requests such information or documents.

طلذ١ذخ وبلخ ئجبثلبد ل الرج لزا ػل رئجبثب أ أ٠ؼب ألش

٠ز ػاللخ راد جش٠خ أخش ؼبد أ بن ١ظ أ دل١مخ،

أللل عللف ألل ألللش وللبشفمبرلل. اللرج للزا فلل ػللب اإلفظللبح

ل زذملك ػشس٠خ رشاب غزذاد أ ؼبد ثأ اإعغخ ثزض٠ذ

( أ٠للب ػلل لل 10خللالي ) الرج للزا فلل امذللخ اؼللبد طلذخ

ربس٠خ ؽت اإعغخ ره اؼبد أ اغزذاد.

I undertake that SAMA may seek additional

information from any third party as it deems

appropriate to verify the information provided in this

Form and assess fitness and propriety for the Proposed

Position.

ؼبد ئػبف١خ أؽشاف أخش فك ب أ ؽتإعغخ أ ألش

اؼللبد امذللخ فلل للزا اللرج رم١لل١ طللذخرللشا بعللجب زم١لل١

امزشح. ظتاششخ اشخض الءخ

I undertake that, as long as I am in Proposed Position,

I will notify SAMA of any material information or

changes affecting the completeness or accuracy of the

answers to this Form within a maximum period of )3(

business days from the day of obtaining the

information and the occurrence of the change; In case

of failing to do so, I shall be responsible for any

stipulated sanctions.

ثاخطلبس ألل علف امزلشح، اظتؽ١خ اعزشاس ف أ، ألش

دللخ ػ رإثش أ شأب جش٠خ رغ١شاد أ ؼبد ثأ اإعغخ

أ٠للب( 3) ألظللبب للذح خلالي رلله اللرج لزا ػلل ئجبثللبر اوزلبي

دبلخ فل ازغ١ ش، دذس أ اؼبد ره ػ دظ ػ

.امشسح ؼمثبد ػشػخ أو عف زه خبفز

اششخاع اشخض

Name of Nominated

Person

اظت امزشح

Proposed Position

ازل١غ

Signature

ازبس٠خ

Date

17

Attestation by the Financial Institution مصا قح المؤسسح الماليح

By attesting this Form, the Financial Institution

believes that the Nominated Person is fit and proper in

accordance with the requirements of the

“Requirements for Appointments to Senior Positions in Financial Institutions Supervised by the Saudi

Arabian Monetary Agency” and the Financial

Institution’s own policies and procedures in regard to

fitness and propriety of persons.

الءلخ اشلخض اإعغلخ اب١لخ رإولذ ،الرج لزا ػ ثبظبدلخ

فللك زطجللبد امزللشح ظللت ػلل للزا اللرج الللغ اششللخ

ازؼ١١ ف ابطت ام١بد٠خ ف اإعغبد اب١خ اخبػلؼخ زطجبد"

اإعغخ ئجشاءاد ع١بعبد "إلششاف إعغخ امذ اؼشث اغؼد

اخبطخ ثالءخ األشخبص. اب١خ

By signing this Form on behalf of the Financial

Institution, I confirm that I have carefully read this

Form after it was completed and signed by the

Nominated Person, and that the information in this

Form is accurate to the best of my knowledge.

أل للشأد أؤولذ اإعغلخ اب١لخ ػل ١بثلخ الرج زا ػ ثبزل١غ

ج١لغ أ ،اششخ رل١ؼ اشخض زا ارج ثؼب٠خ ثؼذ ئوب

.ػ دذ ػ طذ١ذخ ارج زا ف ااسدح اؼبد

اإعغخ اب١خاع

Name of Financial

Institution

اع اغئي

Name of officer

اظت

Position

ازل١غ

Signature

ازبس٠خ

Date

خز اإعغخ اب١خ

Stamp by the Financial Institution

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