5.1 Shareholding (Directly owned or through nominees) Company's Amount %age of Past Date of shareholding name/any of share- share- Remarks incorporation other entity holding holding A B
A. Refers to date of closure or surrender of shares B. Refers to reasons for closure or surrender
5.2 Directorship Past Company's Executive Position held shareholding Date of name/ any or Non- in case of Remarks appointment other entity Executive Executive C D
C. Refers to date of retirement D. Refers to reasons for retirement
5.3 Professional Bodies Past club Name of Membership Position membership Remarks Body Number held (If any) E F
E. Refers to date of retirement F. Refers to reasons for retirement 5.4 Social Clubs Past club Name of Membership Position membership Remarks Body Number held (If any) G H
G. Refers to date of retirement H. Refers to reasons for retirement
5.5 Borrowing Loan/facility 1 2 3 4 5 Name of lending institution Type of facility Amount borrowed Date of offer Security offered Value of security Current outstanding balance Remarks
6.0. ADDITIONAL INFORMATION 6.1 Have you or any entity with which you are associated as director, shareholder or manager, ever held or applied for a licence or equivalent authorisation to carry on any business activity in any country? .......................................................................................................... ......................................................................................................... If yes, give particulars ......................................................................................................... .........................................................................................................
If any such application was rejected or withdrawn after it was made, or any authorisation revoked, give particulars: ........................................................................................................ ........................................................................................................ ........................................................................................................
6.2 Have you at any time been convicted of any criminal offence in any jurisdiction? .......................................................................................................... ..........................................................................................................
If yes, give particulars of the court in which you were convicted, the offence, the penalty imposed and the date of conviction .......................................................................................................... .......................................................................................................... ..........................................................................................................
6.3 Have you, or any entity with which you have been involved, been censured, disciplined, warned as to future conduct, or publicly criticised by a regulatory authority or any professional body in any country? .......................................................................................................... ..........................................................................................................
If yes, give particulars ......................................................................................................... ........................................................................................................ .........................................................................................................
6.4 Have you, or has any entity with which you are, or have been associated as a director, shareholder or manager, been the subject of an investigation, in any country, by a Government department or agency, professional association or other regulatory body? ......................................................................................................... ........................................................................................................
If yes, give particulars. .......................................................................................................... .......................................................................................................... ....................................................................................................
6.5 Have you, in any country, ever been dismissed from any office or employment, been subject to disciplinary proceedings by your employer or barred from entry of any profession or occupation? .......................................................................................................... .......................................................................................................... If yes, give particulars .......................................................................................................... .......................................................................................................... ..........................................................................................................
6.6 Have you failed to satisfy a debt adjudged due and payable by you on order of a court, in any country, or have you made any compromise arrangement with your creditors within the last 10 years? .......................................................................................................... ..........................................................................................................
If yes, give particulars. .......................................................................................................... .......................................................................................................... ....................................................................................................
6.7 Have you ever been declared bankrupt by a court in any country or has a bankruptcy petition ever been served on you? .......................................................................................................... .........................................................................................................
If yes, give particulars ........................................................................................................ ........................................................................................................ ........................................................................................................
6.8 Have you ever been held liable by a court, in any country, for fraud or other misconduct? ................................................................................. ...............................................................................................................
If yes, give particulars .............................................................................................................. .............................................................................................................. ..............................................................................................................
6.9 Has any entity with which you were associated as a director, shareholder or manager in any country made any compromise or arrangement with its creditors, been wound up or otherwise ceased business either while you were associated with it or within one year after you ceased to be associated with it? ............................................................................................................... ...............................................................................................................
If yes, give particulars ......................................................................... .............................................................................................................. .............................................................................................................. ...............................................................................................................
6.10 Are you presently, or do you, other than in a professional capacity, expect to be engaged in any litigation in any country? .............................
If yes, give particulars ..................................................................... ......................................................................................................... ......................................................................................................... .........................................................................................................
6.11 Indicate the names, addresses, telephone numbers and positions of three individuals of good standing who would be able to provide a reference on your personal and professional integrity. The referees must not be related to you, and should have known you for at least five years. ............................................................................................................... ............................................................................................................... ..........................................................................……………................
6.12 Is there any additional information which you consider relevant for the consideration of your suitability or otherwise for the position(s) held / to be held? (The omission of material facts may represent the provision of misleading information) ...............………………………. ............................................................................................................... ...............................................................................................................
N.B. This information given in response to this questionnaire shall be kept confidential by the Bank of Uganda, except in cases provided for by law.