S.I. No. 216/2013 - Personal Insolvency Act 2012 (Authorisation of Approved Intermediaries) Regulations 2013.

1. Current Employment Details

Name of Employer

Address

Position Held

Start Date

2. Previous employer if changed in the last 12 months

3. Qualifications

Please give the following details of any qualifications you have acquired (including membership of professional bodies/associations and the course of study you have completed and passed in relation to the insolvency of individuals and the

Personal Insolvency Act 2012

)

Nature of Qualification

Name of awarding institution/ professional association

Country

Date Obtained (mm/yyyy)

4. Relevant Training or Experience

Please give similar details in relation to any relevant training or experience you have in the provision of financial advice to persons in arrears

Name of Training/ Experience

Name of Institution/professional association/Employer

Duration of training/Length of experience

Date Completed(mm/yyyy)

5. The following questions are to be answered by entering a tick in the appropriate box. Where the response to a question is YES the individual applicant and/or responsible person should provide the following on a separate sheet and referenced to the appropriate question

(a) full details;

(b) a submission on why such act will not adversely affect, to a material degree, his or her ability to act as an approved intermediary or provide approved intermediary services for the applicant.

Are you or have you ever been

Yes

No

A

subject to any disciplinary proceedings or issued with a warning, censure, suspension, reprimand or other administrative or judicial sanction or its equivalent?

B

dismissed or asked to resign and did not resign from a fiduciary appointment or a position of trust whether or not remunerated?

C

a director (or equivalent) of a company that was struck off the register of companies (or equivalent) by the Registrar of Companies (or its equivalent) on an involuntary basis?

D

disqualified or restricted from acting as a director in any jurisdiction or disqualified from acting in any managerial capacity?

E

convicted of an offence which could be relevant to an approved intermediary’s ability to perform his, her or its functions under the Act?

F

subject to a finding, judgment or order made against you by any court, tribunal or administrative enquiry involving fraud, misrepresentation, dishonesty or breach of trust or are you currently subject to any proceedings or investigation for fraud, misrepresentation, dishonesty or breach of trust?

G

in the course of your employment or profession been the subject of enforcement action taken by a regulatory authority under applicable law?

Part D — Approved Intermediary Declaration

I, ______________ (applicant name / responsible person for Approved Intermediary services on behalf of applicant company) apply for authorisation under

section 47

of the

Personal Insolvency Act 2012

on the basis of information supplied on this form and any additional information supplied to the Insolvency Service of Ireland in the course of this application.

I acknowledge that the Insolvency Service of Ireland may process and disclose such information in the performance of its statutory functions or otherwise as may be specifically authorised by law.

I warrant that I have truthfully and fully answered the relevant questions in this application form and disclosed any other information which might reasonably be considered relevant for the purpose of this application.

I am aware that it may be grounds for refusal of my application and/or grounds for revocation of an authorisation approval granted on foot of this application to knowingly or recklessly

a. Provide false or misleading information and/or to make a false or misleading statement (which I acknowledge may include the withholding by me of relevant information) in this application for approval and/or;

b. Fail to inform and/or withhold from the Insolvency Service of Ireland details of any material change in circumstances/new information which is relevant and/or material to this application.

I warrant that I will promptly notify the Insolvency Service of Ireland of any changes in the information I have provided, and supply any other relevant information which may come to light in the period during which the application is being considered by the Insolvency Service of Ireland.

I hereby give permission to the Insolvency Service of Ireland to contact my employer during the period this application is being considered to confirm my employment status and also that I am fit and proper to practise as an approved intermediary.

Signed: ______________

(Applicant/responsible person)

Print Name: ______________

(Applicant/responsible person)

Signed: ______________

(on behalf of Employer)

Print Name: ______________

(on behalf of Employer)

Date: ______________

Part E — Checklist

The Insolvency Service of Ireland will NOT commence the processing of any application if it deems the application to be incomplete. Applications will be deemed incomplete unless all applicable supporting documentation (as outlined in the checklist below) has been received. Incomplete applications will be returned to you as invalid. An application that has to be re-submitted will be dealt with as a brand new application.

Applicant

ISI USE ONLY

Completed Application Form (signed and all questions answered)

Registration of Business Name Certificate (Part A) If applicable, a business name registration certificate issued by the Companies Registration Office must be supplied in relation to all trading names (if different to the legal name) that the applicant wishes to use in relation to approved intermediary practice. Please contact the Companies Registration Office (www.cro.ie) if you have any queries in relation to your business name registration certificate.

Qualification Certificates (Part C)

Signed Declaration (Part D)

GIVEN under the Official Seal of the Minister for Justice and Equality,

21 June 2013.

ALAN SHATTER,

Minister for Justice and Equality.

GIVEN under the seal of the Insolvency Service of Ireland,

21 June 2013.

LORCAN O’CONNOR,

Director of the Insolvency Service of Ireland.

CATHY CLARKE,

A Member of the Staff of the Insolvency Service of Ireland Authorised by the Director of the Insolvency Service of Ireland to Authenticate the Seal of the Insolvency Service of Ireland.

EXPLANATORY NOTE

(This note is not part of the Regulations and does not purport to be a legal interpretation.)

These regulations set out the qualification criteria and authorisation requirements which must be met for a person or a class of person to be authorised by the Insolvency Service of Ireland to carry on the practice of an approved intermediary.

The Minister for Justice and Equality consents to the making of the foregoing Regulations.

6. Driving Licence

Driving Licence Number

Country of Issue

Expiry Date (dd/mm/yyyy)

7. Contact Details

Telephone Number of Principal Business

Mobile Number of Responsible Person

Fax Number

Direct e-mail address (all correspondence from the Insolvency Service of Ireland will be sent to this address)

Website address

Part C — Fitness & Probity

To be completed by an individual applicant and responsible person for approved intermediary services on behalf of a corporate body

8. Name of all Directors (including non-executive Directors) or Partners

First Name

Surname

Date of Appointment

Director Type

9. Details of Shareholders who directly hold shares or other interests representing 10% or more of the voting or capital rights of the applicant

First Name

Surname

% held

Date Acquired DD/MM/YY

Part B — Details of applicant, if an individual or the person who will provide approved intermediary services for the applicant who is a body corporate (responsible person)

Notice of the making of this Statutory Instrument was published in

“Iris Oifigiúil” of

28

th June

, 2013.

The Insolvency Service of Ireland, in exercise of the powers conferred on it by

Section 3

of the

Personal Insolvency Act 2012

and with the consent of the Minister for Justice and Equality, for the purposes of prescribing the criteria for authorisation of persons as approved intermediaries, hereby makes the following regulations

Citation and Purpose