FORM BNM/JKAP/STATDEC/DIR
STATUTORY DECLARATIONS BY CHAIRMAN / DIRECTOR
1. I, _______(name of Chairman/Director) ____, of ___ (address of Chairman/Director)________, NRIC/Passport No_________
do solemnly and sincerely declare that:
A. I am not disqualified under section 59(1) of the Financial Services Act 2013 (FSA) and/or section 68(1) of the
Islamic Financial Services Act 2013 (IFSA) whereby:
(i) I am not an undischarged bankrupt, I do not have any suspended payments and I have not compounded
with my creditors, whether within or outside Malaysia. To my knowledge, there is no bankruptcy
proceeding being initiated against me at present;
(ii) I do not have any charge proven against me for a criminal offence relating to dishonesty or fraud under any
written law or the law of any country, territory or place outside Malaysia;
(iii) I am not prohibited from being a director of a company or in any way, whether directly or indirectly, be
concerned or take part in the management of a company in Malaysia pursuant to a court order made under
section 130A of the Companies Act 1965 and have not obtained any leave of the court under the same
section; and
(iv) Under any law relating to prevention of crime, drug trafficking or immigration:-
(a) There has not been any order of detention, supervision, or deportation made against me; and
(b) There has not been any form of restriction or supervision by bond or otherwise, imposed on.
B. (i) No penalty and no reprimand has been imposed or issued against me by any supervisory authority in or
outside Malaysia; or
(ii) A penalty and/or a reprimand has been imposed or issued against me by a supervisory authority in or
outside Malaysia.
(Delete whichever is not applicable. If (ii) is selected, please provide details, i.e. name of supervisory authority, reasons
and amount of penalty, in a separate attachment)
C. I am : (for director only)(delete whichever is not applicable)
(i) representing the interests of __________________; or
(ii) not representing the interests of any person;
D. I understand that in my tenor as the Chairman/Director of _(name of company)___, I shall not:
(i) engage in any activities or practices that would result in conflict of interest and will disclose any conflicts
which may impair the objectivity and integrity of _(name of company)___;
(ii) hold any directorship in an insurer or a takaful operator or any other insurance broker or takaful broker or
registered as an insurance or takaful agent; and
(iii) hold any shares in an insurer or a takaful operator or any other insurance broker or takaful broker or own
an insurance or a takaful agency agent.
E. All the information submitted in this form and in any attached annexure (if any) is true, correct and complete;
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 DAY OF _______________ 20_______
Before me:
(Signature of Sessions Court Judge,
Magistrate or Commissioner for Oaths)
CONSENT FOR DISCLOSURE OF INFORMATION
Pursuant to paragraph 1 of Schedule 11 of section 134(1)(a) of the Financial Services Act 2013, paragraph 1 of
Schedule 11 of section 146(1)(a) of the Islamic Financial Services Act 2013 and section 120(1)(c) of the Development
Financial Institutions Act 2002, I hereby authorize all the licensed institutions and development financial institutions
where I maintain my accounts or have financial liabilities with, to disclose to Bank Negara Malaysia, any document and
information relating to my affairs, accounts or financial liabilities.
Signature: __________________________________ Date: __________________
Name: ________________________________
Note:
1. A Chairman /Director/applicant from a foreign country is required to make the statutory declaration before the authorized
Diplomatic/Consular Officer at the Malaysia Embassy in that foreign country;
2. Where there is no Malaysian Embassy in that foreign country, as an interim measure, the Chairman /Director may make a
statutory declaration which shall be made under the law relating to statutory declaration or oaths prevailing in that foreign country.
However, the Chairman /Director is required to make a new statutory declaration based on the Malaysian Statutory Declaration
Act 1960 prior to his/her appointment as a Chairman /Director of the approved person in Malaysia; and
3. This statutory declaration cannot be translated to any other language.
