Prospective applicant to e-mail to pdapplication@bnm.gov.my to indicate the intention to submit an application. A preliminary discussion may be arranged to ensure that the prospective applicant is aware of the requirements and application procedures. Please DO NOT submit any formal application yet.Submission of formal application (hardcopy) to Bank Negara Malaysia (BNM). Please provide the soft copy of the application form and appendix (where stated) via email to pdapplication@bnm.gov.my The applicant may be contacted by BNM officers for clarification or request for additional information. Applicants will be given a specified time period to provide the information.If the information/clarification provided is inadequate or not provided within the specified time period, the submission will be returned to the applicant and no longer processed. Otherwise, BNM will proceed to process the application. Applicant will be informed on the result of the application.

1. This application form shall be used for the purpose of submitting an application to issue electronic money (e-money) as a designated payment instrument under Section 11 of the Financial Services Act 2013 (FSA) or the Islamic Financial Services Act 2013 (IFSA). An applicant shall submit a cover letter, the completed application form and appendices (with clear labelling) to:

PengarahJabatan Pemantauan PembayaranBank Negara Malaysia Jalan Dato’ Onn50480 Kuala Lumpur

2. This application form consists of six (6) parts as follows:Part 1: Background, credibility and capabilityPart 2: Financial resourcesPart 3: Product description Part 4: System and securityPart 5: Risk managementPart 6: Others

3. The processing of an application shall involve the following steps:Step 1:

Step 2:

Step 3:

Step 4:

Step 5:

REMINDER This application form must be read together with the relevant provisions in the FSA or IFSA, Guideline

on Electronic Money (E-money), Anti-Money Laundering, Countering Financing of Terrorism and Targeted Financial Sanctions for Financial Institutions (AML/CFT and TFS for FIs) and any other relevant regulations or requirements issued by BNM.

Proper assessment must be made on whether the business model fulfills the definition of e-money, before any submission and payment of fee is made to BNM.

Please ensure that the information provided is complete, valid and contain adequate level of clarity to facilitate processing. Please label supporting documents or appendices clearly to facilitate our assessment.

Processing of applications will only commence once the information and documentations submitted is complete, INCLUDING any subsequent additional clarification or information required from the applicant by BNM.

BNM reserves the right to require additional information or document that is not included in the application form.

Applications with incomplete or unclear information and documents will be RETURNED to the applicant. A cooling off period of three (3) months shall be observed for a closed/ returned application, while a

cooling off period of at least six (6) months shall be observed for a rejected application before the Background information on Alliance Bank is attached in Appendix I.

BANK NEGARA MALAYSIA

APPLICATION FORM TO ISSUE E-MONEY AS A DESIGNATED PAYMENT INSTRUMENT

applicant is allowed to resubmit the application. BNM reserves the right to impose a longer cooling off period on a case-by-case basis.

Please do not alter/amend any words or sentences provided by BNM in the form.

2

Part 1: Background, credibility and capabilityNot applicable for applicants which are financial institutions regulated by BNM

(a) Applicant’s particularsName of company Telephone no.

Company registration no.

Fax no.

Date of incorporation Month/Year of commencement of business operations Place of Incorporation

Business address

Contact person Name:Telephone number:E-mail address:Designation:

Company’s business activities and products / services offered Including Group’s

business activities if company is part of Group of companies

Documents to be enclosed:Please tick (X) and provide the required documents in accordance to the Appendix reference below.

1. Appendix A : Certified true copy of company’s registration form1 or memorandum and articles of association or other constituent documents2 under which it is established (whichever applicable)

2. Appendix B : Certified true copy of certificate of incorporation or business registration

3. Appendix C : Certified true copy of latest audited financial statements or, in the case of a new company which has yet to complete its first financial year cycle, please provide the following:

Appendix C1 : Return on allotment of shares under the Companies Act 2016 (if applicable);

Appendix C2 : Latest bank statement; and

Appendix C3 : Latest unaudited management account.

4. Appendix D : Statutory declaration declared before an authority, e.g. Commissioner of Oath as per the Statutory Declaration Act 1960 from the applicant stating that it has not been subjected to any regulatory action, criminal convictions, records or dishonesty, fraud or violence, or breaches of statutory or other administrative or regulatory enactments (refer to attached template in Appendix 1)

5. Appendix E : Undertaking by the applicant to keep BNM informed of any material adverse developments affecting its financial soundness and/or reputation.

Appendix F : Certified true copy of Board resolution or resolution of the highest decision making body of the applicant approving the application to issue electronic money

Appendix G : Details of any approval, authorisation, licence or permit required by or obtained from any regulatory authority, including a

certified true copy of such approval, authorisation, licence or permit (if applicable)

1 Under Companies Act 2016.2 Under Companies Act 1965.

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(b) Details of shareholders If space provided is insufficient, please provide in a separate sheet

Name (Individual or company)

NRIC/ passport/ BRIC3 number

Nationality Home address Amount of shareholding (RM)

% of shareholding

1.

2.

3.

4.

5.

Total 100%Documents to be enclosed:Please tick (X) and provide the required documents in accordance to the Appendix reference below.

For individual shareholder (for foreign individuals, please provide the equivalent insolvency and credit report from home country):

1. Appendix H1 : Insolvency report from Malaysia Department of Insolvency and;

2. Appendix H2 : CCRIS report

For company shareholder:

3. Appendix I1 : Certified true copy of company registration form issued by Companies Commission of Malaysia (if applicable)

4. Appendix I2 : Certified true copy of company’s memorandum and association (if applicable)

(c) Corporate structure (applicable if applicant is part of group of companies)

Document to be enclosed:Please tick (X) and provide the required documents in accordance to the Appendix reference below.

Appendix J : Corporate group structure (in a diagram), with adequate details of the parent company, subsidiaries and related companies, including ownership structure and percentage of shareholding (please provide soft copy of this Appendix)

(d) Details of Board of Directors (Board), Chief Executive Officer (CEO) and its committees If space provided is insufficient, please provide in separate sheet

Name Type of directorship (e.g. non-executive/executive, independent/non-independent)

Involved in day-to-day activities of the company (Yes / No)

1.

2.

3.

4.

5.

(e) Organisational structure of the company

Document to be enclosed:Please tick (X) and provide the required documents in accordance to the Appendix reference below.

Appendix K : Current organisational chart, showing Board of Directors, CEO, departments (including the Heads of Departments) and control functions (i.e. internal audit, compliance and risk management) with reporting lines, as well as, staff headcount (including number of vacant positions, if such positions are not yet filled-up) (please provide soft copy of this Appendix)

Appendix L : Plans and timeline to fill in the key positions which are vacant stated under Appendix K above (if applicable)

Part 1A: Form to be completed by Director, CEO and senior management4

3 Business registration or identity card number.4 Head of departments or equivalent and above.

4

Please make copies of Part 1A and fill up specifically for each individual

Reminder: The applicant shall ensure that its Directors, CEO and senior management fulfill the fit and proper requirements specified by BNM and possess the appropriate knowledge and experience.(a) Designation of key responsible person

Please tick (X) where applicable. Tick more than one box if you hold more than one positionDirector Chief Executive OfficerSenior management (please state designation): __________________________________

(b) ParticularsNameNRIC/ passport/ BRIC5 numberNationality Home address Contact numberE-mail address(c) Working experience

If space provided is insufficient, please provide in separate sheetPosition/ Designation Organisation/Company Work activity/Key projects Duration of service

(Year to year)1.

2.

3.

4.

Do you have relevant working experience in payments related area (e.g. e-money, payment cards, merchant acquiring, payment system/gateway or remittance)?

Yes. (Please ensure such experience is reflected in the table “Working Experience” above)

5. No

(d) Educational background (Highest qualification)

Level Institution Year obtained

1.

2.

Are you involved or have been involved (e.g. as a shareholder, director, CEO or senior management) in any other business regulated by BNM? If yes, please complete the following:

Name of business Business activity Type of interest(e.g. shareholder, director, CEO, senior management)

Year

1.

2.Documents to be enclosed:Please tick (X) and provide the required documents in accordance to the Appendix reference below (for foreign individuals, please provide the equivalent insolvency and credit report from home country)

Appendix M : Statutory declaration as per Appendix 2

Appendix N : Insolvency report from Malaysia Department of Insolvency

6. Appendix O : CCRIS report

Part 2: Financial resourcesNot applicable for applicants which are financial institutions regulated by BNM(a) Financial resources to fund or support the business

5 Business registration or identity card number.5

Reminder: An applicant shall demonstrate its ability to maintain minimum shareholders’ funds of RM5 million for large6 e-money scheme or RM100,000 for small7 e-money scheme, minimally for the first 3 years of projected operations (Refer to Appendix 3 for computation of minimum shareholders’ funds)

Current and projected capital position This is intended to assess the applicant’s ability to maintain the shareholders’ funds requirement taking into consideration projected profit/loss.Does the company’s current shareholders’ funds meet the capital requirements stated above? Yes. If yes, please answer (i) only.

No. If No, please answer (i), (ii) and (iii) below.

(i) What is the current amount of the company’s shareholders’ funds? RMShare capital (ordinary shares only)

(+) Reserves - including share premium and general reserve fund(+) Retained Profit or (-) Accumulated Losses(+) Profit for the period or (-) Loss for the period(-) Intangible assets

(=) Shareholders’ Funds

(ii) Please provide the source and amount of additional capital to be injected in order to fulfil the capital requirements Note: If the source of capital is provided by an individual, only capital in the form of liquid assets are acceptable, e.g. balances in bank account

Source of capital Amount (RM)

When can the additional capital be obtained?

1.2.3.

(iii)Please provide evidence of capital provider’s financial capability to provide additional capital to ensure sufficient shareholders’ funds

Documents to be enclosed as evidence:Please tick (X) and provide the required documents in accordance to the Appendix reference below.

For individual:

Appendix P1 : Bank statement showing adequate balances to support the proposed additional capital

Appendix P2 : Letter of commitment (indicating the amount) to provide the capital

For company:

Appendix P3 : Latest audited financial statements or latest unaudited management account showing adequate cash balances or cash balances equivalents, as well as, positive shareholders’ funds

Appendix P4 : Letter of commitment (indicating the amount) to provide the capital

Part 3: Product description

(a) Detailed description of the proposed payment instrumentIf space provided is insufficient , please provide in separate sheet and provide the attachment reference

Name of e-money productType of payment Please tick if offered:

6 Refers to e-money scheme with: (i) purse limit exceeding RM200 (maximum limit is capped at RM1,500 or any amount as approved by BNM); or(ii) outstanding e-money liabilities for 6 consecutive months amounting to RM1 million or more.

7 Refers to e-money scheme with:(i) purse limit not exceeding RM200; and(ii) outstanding e-money liabilities of less than RM1 million.

6

instrument Prepaid card

Physical Virtual Proprietary International Network:_____________

(e.g. VISA, MasterCard)E-wallet via mobile app

E-wallet via online portal

Others, please explain: ________________________

Technology used Please tick where applicable:

EMV/contactless cards

Unstructured Supplementary Service Data (USSD)

Short Messaging System (SMS)

Near Field Communication (NFC)

Quick Response (QR) code

Others, please explain: _________________________

Wallet limit (i.e. maximum monetary value that can be stored in an e-money)

RM:_________________________

Rationale for the requested wallet limit(if applying for large scheme, please include the rationale, e.g. business needs)(b) Description and the process flow for the following items (i) to (ii), including the security controls

applicable for each item (e.g. multifactor authentications such as one-time password-OTP), for each of the functions and services below

(i) Functions Documents to be enclosed for ALL the functions:

a) Front-end process flow (e.g. diagram/ screenshot); and

b) Back-end process flow.

Please tick (X) and provide the required documents for ALL the functions below

App download / access to portal

Registration and due diligence for:

Users Merchants Reload agents

Reload via: (including turnaround time)

Cash Internet banking Debit card

Credit card Others, please explain:____________

Refund via: (including turnaround time)

Cash Internet banking Debit card

Credit card Others, please explain:____________

Account closure (including turnaround time)

Dispute resolution (including turnaround time)

Settlement arrangement with all relevant parties (including turnaround time)

Any other functions involved

(ii) ServicesDocuments to be enclosed for EACH OF THE APPLICABLE services:

a) Front-end process flow (e.g. diagram/ screenshot); and

Please tick (X) and provide the required documents for EACH OF THE APPLICABLE services below

Purchase

Physical merchant Online In-app Details:__________ Details:__________ Details:__________ (e.g. face-to-face transaction) (e.g. e-commerce, games credit) (e.g. airtime reload)

7

b) Back-end process flow. Funds transfer

To other e-money account (peer-to-peer/ P2P funds transfer)

To own bank account

Others, please explain:____________

Withdrawal

Cash Bank account Others Details:_________

Cross-border remittance

Any other services available

(c) Value proposition and target market(Reasons why the applicant believes the proposal will be feasible and business will be viable)If space provided is insufficient , please provide in separate sheet and provide the attachment reference

Description of the target market

Users: _________ (e.g. students, corporates)

Merchants: ________ (e.g. online, e-hailing)

Locations: ________ (e.g. Klang Valley, East Malaysia, outside Malaysia)

Others (if any): ________

Size of target market (for the 1st year of e-money operations)

Estimated number of users : _____

Estimated number of merchants: _____

Evidence of demand from the potential user/ merchant base that have been identified as the target market

Document to be enclosed as evidence:Please tick (X) and provide the required documents below

o Appendix Q : Letter of interest, MoU or survey response from at least 100 users or 10 merchants in the target market (for small e-money scheme) or 500 users or 20 merchants (for large e-money scheme). For this purpose, users can also be represented by the organization of which the users are connected to (e.g. an MoU from a single university may represent all the students in the university as potential users of the product)

Describe the benefits/additional value of the product to the target market (e.g. Target market yet to have any access to e-money/underserved segments, environmental/sustainable activities, etc.)

(d) For application to issue a designated Islamic payment instrument pursuant to section 9 of the IFSA (if applicable)

Document to be enclosed:Please tick (X) and provide the required documents below.

Appendix R : Attestation from a qualified Shariah advisor8 on the Shariah aspects of the payment instrument including application of Shariah contracts and operational arrangement of the payment mechanism of the payment instrument to ensure compliance with Shariah.

Part 4: System and securityReminder: The applicant shall demonstrate that it has the capability to ensure a robust system and security measures and infrastructure are in place for the proposed product.(a) Overview of system and securityOverview of network and security architecture (including placements of relevant servers and security devices within the network zones e.g. untrusted zone,

Document to be enclosed:Appendix S : DIAGRAMMATIC ILLUSTRATION with adequate description of the network architecture of items below. The diagram includes the following (please tick (X) where applicable):

8 May include individuals, companies or existing Shariah Committee endorsed by BNM.8

demilitarized zone (DMZ) and secured zone)

For end-to-end communications including connectivity between endpoint, data centre and host system and third party integrations

End-to-end communication

Data centres (production and recovery)

Servers

Firewalls

Intrusion prevention system (IPS)

Other devicesDetails: ___________________________________________________

Details of data/network/communications encryption standards used For end-to-end communications including connectivity between endpoint, data center and host system and thirdparty integrations

Data encryption (including the encryption type, version and strength)Details: ___________________________________________________

Network encryption (including the encryption type, version and strength)Details: ___________________________________________________

Communication session encryption (including the encryption type, version and strength)Details: ___________________________________________________

Hashing algorithms (including the encryption type, version and strength)Details: ___________________________________________________

OthersDetails: ___________________________________________________

Methods used for prevention and detection of fraud/scam(Example of fraud: card/device theft, account takeover, card clone)(Example of scam: phishing)

Image verification upon log-inDetails: ___________________________________________________

Word/ number verification method upon log-inDetails: ___________________________________________________

Awareness programs:

On website Details: ___________________________________________________

Brochures Details: ___________________________________________________

At partners’ premise Details: ___________________________________________________

Others Details: ___________________________________________________

Call back customer checksDetails: ___________________________________________________

SMS alert/ notification on suspicious activities e.g. login and transactionsDetails: ___________________________________________________

Detection system and methods used to monitor e-money transaction anomalies:

Real-time monitoring

Details: ___________________________________________________

Daily monitoring Details: ___________________________________________________

Others Details: ___________________________________________________

Establish transaction limit

Daily cumulativeAmount: ___________________________________________________

Transaction 9

Amount: ___________________________________________________

OthersAmount: ___________________________________________________

Security devices/methods used for protection against cyber threats Yes. This includes:

Firewall (2 tiers) Details (including type and name):___________________________________________________

Anti-virus Details (including type and name):___________________________________________________

System session communication security Details (including type and name):___________________________________________________

DDoS protection Details (including type and name):___________________________________________________

Spam protection Details (including type and name):___________________________________________________

Malware protection Details (including type and name):___________________________________________________

Security monitoring via security incident event management (SIEM)Details (including type and name):___________________________________________________

Others Details:___________________________________________________

Network and application vulnerability assessment and penetration testing

Yes. Please provide copy of reportDetails (including testing cycle):________________________________________________________

None. Please provide plan.Details: _________________________________________________

IT certificationYes. Please provide copy of certification reportType of certification: ______________________________________

Purpose of certification: ___________________________________

None.

Documents to be enclosed:Please tick (X) and provide the required documents in accordance to the Appendix reference below.

Appendix T1 : Network and application vulnerability assessment/ penetration testing report of the solution including rectification of issued raised

Appendix T2 : DIAGRAMMATIC ILLUSTRATION with adequate description of the network segment/security zone (logical grouping of the systems in the network and its security implementation)

Appendix T3 : Certification obtained, e.g. Information Security Management System (ISMS) certification

(b) Describe the security measures deployed on user’s mobile app/ mobile device and merchant’s endpoint devices (if applicable) to mitigate cyber threats:

Types of mobile phone operating systems allowed for installation of wallet app and facilitation of transactions (e.g. Android, IOS, etc.)

AndroidVersion: ____________________________________________

IOS

10

Version: ____________________________________________

OthersVersion: ____________________________________________

Methods used for binding of customer’s or merchant’s app to the endpoint device

Yes. The mobile app is tied with a unique device ID using:

International Mobile Equipment Identity (IMEI)Details: ____________________________________________

Digital certificateDetails: ____________________________________________

OthersDetails: ____________________________________________

None.

Methods used for protecting e-wallet from being used on unsecured phone and outdated versions

YesDetails: ___________________________________________

None. Multi-factor authentication deployed Yes.

Describe the type of authentication used:

What you know Details: (e.g. password, PIN code) ______________________________________________________

What you haveDetails (e.g. SMS TAC/One-Time Password) : ______________________________________________________

Who you areDetails (e.g. biometrics) : ______________________________________________________

Others:Details: ________________________________________________

None.

Notifications deployed to facilitate transactions (eg. notification for every successful transactions)

Yes. Using:

SMSDetails: ____________________________________________

EmailDetails: ____________________________________________

OtherDetails: ____________________________________________

None.

Methods to prevent usage of app on jail-broken or rooted end-point devices

YesDetails: ___________________________________________

None.

Method for installation of e-wallet app on customer/ merchant devices

YesDetails: ___________________________________________

None.

Methods to prevent fake or counterfeit app existing in Google Yes

Details: ___________________________________________

11

or Apple stores None.

Enforcement of geo-location tracking for all registrations and transactions

YesDetails: ___________________________________________

None.

Restriction of fund transfers, i.e. to allow transfers to be conducted within Malaysia (if funds transfer service is provided)

YesDetails: ___________________________________________

None.

Details of POS terminal security configuration for protection against cyber threats (e.g. malware attacks)

Details of network encryption for communication between the merchant, POS service provider and the institution’s host server (including the encryption type, version and strength)

(c) Describe the security measures deployed for products that involve QR codes (if applicable):Description of the type of QR code used Static

Details: ____________________________________________

DynamicDetails: ____________________________________________

Validity: ____________________________________________

OthersDetails: ____________________________________________

Security details of QR code Code contents: ______________________________________________________

Encryption (type version and strength): ______________________________________________________

Code generation process (including token): ______________________________________________________

Code usage: ______________________________________________________

Code storage: ______________________________________________________

Other security details: ______________________________________________________

Methods for detecting and blocking usage of illegitimate QR codes

Yes.Details: _________________________________________________

None.

Part 5: Risk managementIf space provided is insufficient, please provide in separate sheet and provide the attachment reference

12

(a) Internal audit function

Current Proposed(if vacant during application stage)

For in house functionName of departmentName of officerQualificationExperience

If outsourced or involve internal audit of groupName of outsourced party/ function in the groupBackground info (e.g. track record, type of assurance services provided)(b) Compliance function

Current Proposed(if vacant during application stage)

NameQualificationExperience (c) Risk management function

Current Proposed(if vacant during application stage)

NameQualificationExperience

(d) Risk management, internal control, as well as, policies and procedures Reminder: The applicant shall demonstrate understanding of the risks involved in the proposed e-money business and shall identify adequate risk mitigation measures to manage such risks.

Summary of assessment on major risk areas:If space provided is insufficient, please provide in a separate sheet and provide the attachment referenceType of risk Level of risk

(High, Medium, Low)Description of the potential risk

involved with regards to the proposed e-money business

Risk mitigation measures (for high/ medium risk)

Operational e.g. inadequate/ failed internal processes or human error

ML/TF e.g. inability to verify customer information due to current system/ resource/operational limitations

Security/ Technology e.g. product may be vulnerable to cyber-attack, system hacking or disruption due to current limitation of system/architecture

Fraud/Scam e.g. vulnerability of product to fraud or scam due to limitations in current infrastructure/operational procedures

Others (e.g. Legal, Outsourcing, Market risk)Measures for the management of funds collected from users (do not include own working capital)[Refer to Principle 4 of the Guideline on E-Money]

Current Proposed

Trust account (for large scheme)

Name of trustee

Name of bank

Dedicated deposit account (for small scheme)

Name of bank

13

Others, to explain

Measures for business continuity and plan for disaster recovery of the system

Please describe key measures for business continuity planning:

____________________________________________________

Location of production site: ______________Location of alternative site: ______________

Measures for the management of AML/CFT risks If space provided is insufficient, please provide in a separate sheet

[Refer to Anti-Money Laundering, Countering Financing of Terrorism and Targeted Financial Sanctions for Financial Institutions (AML/CFT and TFS for FIs)]

Type of business

relationship (i.e. face-to-face or non face-to-face)

When CDD9

is conducted

List of information/ documents requested

Method10 of verification

For customersFor merchantsFor reload agents

Will the company appoint 3rd party/ agent to conduct on-boarding of customers? Yes. Please answer the following: No

(i) Describe key roles and responsibilities of the 3rd party/ agent. _________________________________________________

(ii)How do the company ensure proper conduct of the 3rd party/ agent? _________________________________________________

(e) Outsourcing arrangement (if applicable)

Description of any outsourcing arrangement

Current Proposed(for potential areas/ functions)

Name of outsourced partyAreas/ functions outsourcedRoles and responsibilities of the outsourced party

Part 6: OthersProcessing feeAn applicant is required to pay a fee of RM500 to BNM via the following channel:a) RENTAS with TRN code OBT01, account number

1547010015; orb) Internet banking to Maybank account number of

514150127067 under the name of Bank Negara Malaysia.Such fees shall be paid by the applicant not later than seven (7) working days from the date the application is submitted to BNM.

Documents to be enclosed:Please tick (X) and provide the required documents

Appendix U : Receipt or proof of payment for processing fee.

Attestation by applicant

We hereby certify to the best of our knowledge that the information provided are true and correct, that all available information and data have been supplied herein, and that we agree to show documentary proof and additional information thereof upon BNM’s request.

Name of Authorized Representative (Chief Executive Officer):

__________________________________

Signature:__________________________

9 E.g. During on-boarding stage or when customer perform transaction that require CDD.10 E.g. Matching of customer’s photo in the ID with the selfie.

14

Date:______________________

Appendix 1Statutory Declaration from the Applicant

I, ......................................... (name), of *NRIC / *Passport No. ........................ the ................................(state the position) of ................................(“Applicant”) do solemnly and sincerely declare that:

A. The applicant has not been the subject of any regulatory actions, criminal convictions, records of dishonesty, fraud, or violence or breaches of statutory or other administrative or regulatory enactments; and

B. The applicant has submitted an application for approval from Bank Negara Malaysia under Section 11 of the Financial Services Act 2013 or Islamic Financial Services Act 2013. The applicant understands that if the applicant furnishes any information required which is false, inaccurate, misleading or contains material errors or omissions, the approval may not be granted by Bank Negara Malaysia. In the event that the approval has been granted, it may be revoked.

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Statutory Declarations Act 1960.

Subscribed and solemnly declared by the abovenamed .......................................) at..............................) in the State of......................) this.......................20..............)

Before me:

15

....................................................... (Signature of Sessions Court Judge, Magistrate or Commissioner of Oaths)

Appendix 2Statutory Declaration from the Directors, CEO and Senior Management11

I, .................................................................... (name), of *NRIC / *Passport No. ............................. the ............................... (state the position) of .................................... (“Applicant”) since ........................ (date) do solemnly and sincerely declare that:

A. I am not subject to the disqualifications mentioned below:

(i) I have not been the subject of any regulatory actions, criminal convictions, records of dishonesty, fraud or violence or breaches of statutory or other administrative or regulatory enactments;

(ii) I have not been involved as a senior officer or a member of the senior management of any company which has been the subject of any regulatory actions, criminal convictions, records of dishonesty, fraud or violence or breaches of statutory or other administrative or regulatory enactments; and

B. The applicant has submitted an application for approval from Bank Negara Malaysia under section 11 of the Financial Services Act 2013. I understand that if I furnish any information required which is false, inaccurate, misleading or contains material errors or omissions, the approval may not be granted by Bank Negara Malaysia. In the event that the approval has been granted, it may be revoked.

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Statutory Declarations Act 1960.

11 Head of departments or equivalent and above.16

Subscribed and solemnly declared by the abovenamed ..................................) at...........................) in the State of.........................) this..................20..............)

Before me: .......................................................... (Signature of Sessions Court Judge, Magistrate or Commissioner of Oaths)

17

Appendix 3

Computation of shareholders’ funds

Share capital which includes:

Paid-up ordinary shares/common stock

plus Reserves which includes:

Share premium

General reserve fund

plus Retained Profit (or less Accumulated Losses)

plus Audited Profit for the period (or less Unaudited Loss for the period)

less Intangible Assets12

12 Including goodwill, capitalised development costs, licenses and intellectual properties.18