INTERMEDIARIES & INVESTMENT PROFESSIONALS ONLY: NOT FOR PUBLIC DISTRIBUTION
Mortgage and General Insurance Registration form – New Firm/Returning Firm Please fill in the form using BLOCK CAPITALS and black ink. Tick any boxes which apply.
Santander is able to provide literature in alternative formats. The formats available are: large print, Braille and audio CD. If you would like to register to receive correspondence in an alternative format please visit www.santander.co.uk/alternativeformats for more information, ask us in branch or give us a call. Important information We are committed to Mortgage and General Insurance for Intermediaries. Our aim is to build a business relationship with you, providing the service you need to make your life as easy as possible. By spending a few minutes completing this form we will be able to set up your company details on our database so we know how and where to contact you with product details and for payment of fees. Thank you for your interest in registering as an Intermediary with us. We look forward to developing a strong business relationship. 1
Firm details
Full legal name of business
Country of operation (if different from country of incorporation)
Business/trading name to be used on documentation (if different from above)
Firm FCA number Regulated activity (Please tick all that apply)
Country of incorporation (i.e. in which country was the company established?)
Mortgages General Insurance
Companies House number
Both
2 Firm contact details Full business address (Registered office)
Telephone number Fax number
Postcode
Email address
Full trading address/address for fee statements (if different from above)
Postcode 3A Owners/Partners/Directors/major shareholders (holding shares of 25% or more in the firm, regardless of whether or not they process business) First owner/partner/director
Alias used, if applicable:
Title
Alias title
Mr
Mrs
Ms
Miss
Mr
Mrs
Other
Other
First name
Alias first name
Middle names(s)
Alias middle name(s)
Surname
Alias surname
Ms
Miss
Page 2 of 6 3A Owners/Partners/Directors/major shareholders (holding shares of 25% or more in the firm, regardless of whether or not they process business) (continued) Date of birth D D
M M
Y
Y
Y
Y
Employment / Self-employment history (please provide details covering the last 5 years, noting any time in education or unemployment. Continue on a separate sheet if necessary)
Place of birth (town and country)
Name of business
Nationality (including dual nationality, if applicable)
Address
Home address
Postcode Dates of employment
From
To
Name of business Postcode
Address
Position in firm (owner/partner/director etc.)
Postcode Dates of employment
Date position acquired D D
M M
Y
Y
Y
Y
From
To
Name of business Address
National Insurance number
Postcode
Country of residence
Dates of employment
From
To
3B Owners/Partners/Directors/major shareholders (holding shares of 25% or more in the firm, regardless of whether or not they process business) Second owner/partner/director
Place of birth (town and country)
Title Mr
Mrs
Ms
Miss
Nationality (including dual nationality, if applicable)
Other Home address
First name
Middle names(s) Postcode
Surname
Position in firm (owner/partner/director etc.) Alias used, if applicable: Date position acquired
Alias title Mr
Mrs
Ms
Miss
D D
M M
Y
Y
National Insurance number
Other Alias first name
Country of residence Alias middle name(s)
Alias surname
Date of birth D D
Y
M M
Y
Y
Y
Y
Y
Page 3 of 6 3B Owners/Partners/Directors/major shareholders (holding shares of 25% or more in the firm, regardless of whether or not they process business) (continued) Employment / Self-employment history (please provide details covering the last 5 years, noting any time in education or unemployment. Continue on a separate sheet if necessary)
Name of business Address
Name of business
Postcode
Address
Dates of employment Postcode
Dates of employment
From
From
To
Name of business
To
Address Postcode Dates of employment
From
To
3C Owners/Partners/Directors/major shareholders (holding shares of 25% or more in the firm, regardless of whether or not they process business) Third owner/partner/director
Position in firm (owner/partner/director etc.)
Title Mrs
Mr
Ms
Miss
Date position acquired D D
Other
M M
Y
Y
Y
First name
National Insurance number
Middle names(s)
Country of residence
Surname
Y
Employment / Self-employment history (please provide details covering the last 5 years, noting any time in education or unemployment. Continue on a separate sheet if necessary)
Alias used, if applicable:
Name of business
Alias title Mr
Mrs
Ms
Miss
Address
Other
Postcode
Alias first name
Dates of employment
Alias middle name(s)
Name of business
From
To
Address Alias surname
Postcode Dates of employment
From
To
Date of birth D D
M M
Y
Y
Y
Name of business
Y
Address
Place of birth (town and country)
Nationality (including dual nationality, if applicable)
Home address
Postcode
Postcode Dates of employment
From
To
Page 4 of 6 3D Owners/Partners/Directors/major shareholders (holding shares of 25% or more in the firm, regardless of whether or not they process business) (continued) Fourth owner/partner/director
Position in firm (owner/partner/director etc.)
Title Mr
Mrs
Ms
Miss
Date position acquired D D
Other
M M
Y
Y
Y
First name
National Insurance number
Middle names(s)
Country of residence
Surname
Y
Employment / Self-employment history (please provide details covering the last 5 years, noting any time in education or unemployment. Continue on a separate sheet if necessary)
Alias used, if applicable:
Name of business
Alias title Mr
Mrs
Ms
Miss
Address
Other
Postcode
Alias first name
Dates of employment
Alias middle name(s)
Name of business
From
To
Address Alias surname
Postcode Dates of employment
From
To
Date of birth D D
M M
Y
Y
Y
Name of business
Y
Address
Place of birth (town and country)
Nationality (including dual nationality, if applicable)
Postcode Dates of employment
From
To
Home address
Postcode If there are more than 4 owners/partners/directors/major shareholders, please print and complete any additional pages required
Page 5 of 6 4 Owners/Partners/Directors/major shareholders - Financial and personal history Have any of the owners, partners or directors of the firm at any time: A. Been the subject of any investigation, inquiry, or regulatory/ enforcement action or proceedings involving actual or alleged financial crime? Yes
No
B. Been disqualified from acting as a company director? No
Yes
C. Been the subject of a receiving order?
H. Been the subject of a court judgement for any outstanding debts? Yes
No
I. Been convicted of a criminal offence? Yes
No
If you have answered ‘yes’ to any of the preceding questions, please provide further information below, continuing on a separate sheet if necessary
No
Yes
D. Defaulted on a credit agreement? Yes
No
E. Entered into an arrangement with creditors? Yes
No
F. Been declared bankrupt? Yes
No
G. Been a director of a company which has wound up and declared bankrupt? No
Yes
5
Professional standing
A. Does your firm trade entirely from the UK? No
Yes
B. Does your firm have policies and procedures in place designed to prevent and detect all forms of financial crime (fraud, bribery, corruption and money laundering)?
C. Do your firm’s staff receive financial crime prevention, fraud, bribery, corruption and money laundering training? Yes
No
No
Yes
6 Introducing Business Do you as a business currently accept any business referrals from introducers – i.e. unregulated individuals or companies? Yes
No
If you have answered ‘No’, please ignore the remainder of this section.
Please provide the full name(s), business name(s) and addresses for each introducer with whom you deal, continuing on a separate sheet if necessary. Name of business Address
What percentage of your overall business is referred from introducers?
% What percentage of the above is conducted on a non face-to-face basis?
%
Postcode Name of business Address
How was contact with introducer established? Postcode
What due diligence was performed?
Page 6 of 6 7
Declaration for and on behalf of the intermediary firm
I/We have read and agree to the Mortgage and General Insurance Terms of Business with Santander UK plc. We will search at credit reference and fraud prevention agencies who will provide us with publicly held data, including the electoral roll. If you give us false or inaccurate information, details may be passed to the credit reference and fraud prevention agencies. We will use the information provided to us by credit reference and fraud prevention agencies to help decide your identity and for the prevention and detection of fraud and/or money laundering.
search footprint on your credit report. This search will not affect your ability to gain credit. The information which we provide to the credit reference and fraud prevention agencies may be supplied by the credit reference agencies to other organisations and used by them to do similar checks, debtor tracing and debt collection and account management.
When credit reference agencies receive a search from us they will place a First owner/partner/director
Third owner/partner/director
Signed
Signed
Date D D
M M
Y
Y
Y
Date D D
Y
M M
Y
Y
Second owner/partner/director
Fourth owner/partner/director
Signed
Signed
Date D D
M M
Y
Y
Y
Date D D
Y
M M
Y
Y
Y
Y
Y
Y
If there are more than 4 owners/partners/directors/major shareholders, please print and sign any additional copies of this page required.
ONCE COMPLETE PLEASE FAX TO 0845 602 3293
Santander for Intermediaries is a brand of Santander UK plc and is not a regulated company.
MORT 0377 SEP 16 HT
Santander UK plc. Registered Office: 2 Triton Square, Regent’s Place, London, NW1 3AN, United Kingdom. Registered Number 2294747. Registered in England and Wales. www.santander.co.uk. Telephone 0800 389 7000. Calls may be recorded or monitored. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Our Financial Services Register number is 106054. Santander and the flame logo are registered trademarks.
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