Notification form for the list of members of the management body of an APA or an ARM
ANNEX IISupplementary provisions
ANNEX II Notification form for the list of members of the management body of an APA or an ARM Reference number: Date: From: Name of the applicant: Address: Legal Entity Identifier (where applicable): (Contact details of the designated contact person at the applicant) Full name: Telephone: Email: To: ESMA/National Competent Authority: Address: (Contact details of the designated contact point at ESMA/National Competent Authority) Address: Telephone: Email: Dear [ insert appropriate name ], In accordance with Article 2 of Commission Implementing Regulation (EU) 2025/1157 please find attached the notification relating to the members of the management body. — Person at the applicant in charge of preparing the notification: Full name: Status/position: Telephone: Email: Date: Signature: — List of members of the management body: Member 1 Full name: Date and place of birth: Personal national identification number or equivalent thereof: Private address: Contact details (telephone and email address): Position: Curriculum vitae attached to application: Yes/No Professional experience and other relevant experience: Educational qualification and relevant training: Confirmation, where possible via an official certificate, of the absence of criminal records relating to money laundering, terrorist financing, financial or data services, acts of fraud or embezzlement OR self-declaration of good repute and authorisation to the competent authority to request information under Article 5(1), point (d), of Commission Delegated Regulation (EU) 2025/1143: Self-declaration of good repute and authorisation to the competent authority to request information under Article 5(1), point (e), of Delegated Regulation (EU) 2025/1143: Minimum time (approximate) that will be devoted to the performance of the person’s functions within the APA or ARM: Declaration of any potential conflicts of interest that may exist or arise in performing the duties and how these conflicts are managed: Additional information relevant for the assessment whether the member is of sufficiently good repute, possesses sufficient knowledge, skills and experience and commits sufficient time to perform the duties pursuant to Article 27f(3) of Regulation (EU) No 600/2014: Effective date: [ Please set out that information here or provide an explanation of how it will be provided, or make reference to the relevant annexes containing the information ] Member [N] Full name: Date and place of birth: Personal national identification number or equivalent thereof: Private address: Contact details (telephone and email address): Position: Curriculum vitae attached to application: Yes/No Professional experience and other relevant experience: Educational qualification and relevant training: Confirmation, where possible via an official certificate, of the absence of criminal records relating to money laundering, terrorist financing, financial or data services, acts of fraud or embezzlement OR self-declaration of good repute and authorisation to the competent authority to request information under Article 5(1), point (d), of Delegated Regulation (EU) 2025/1143: Self-declaration of good repute and authorisation to the competent authority to make enquiries under Article 5(1)(e) of Delegated Regulation (EU) 2025/1143: Minimum time (approximate) that will be devoted to the performance of the person’s functions within the APA or ARM: Declaration of any potential conflicts of interest that may exist or arise in performing the duties and how these conflicts are managed: Additional information relevant for the assessment whether the member is of sufficiently good repute, possesses sufficient knowledge, skills and experience and commits sufficient time to perform the duties pursuant to Article 27f(3) of Regulation (EU) No 600/2014: Effective date: [ Please set out that information here or provide an explanation of how it will be provided, or make reference to the relevant annexes containing the information ]