Form CBK DCP 2

FORM CBK DCP 2 (Regulations 4 and 7)
FIT AND PROPER FORM FOR DIRECTORS, CHIEF EXECUTIVE OFFICER AND
SENIOR OFFICERS
NB: This form should be duly completed, accompanied by the complete set of documents required
under Part III and submitted to the Bank.
1. DIGITAL CREDIT PROVIDER
Name.............................................................................................................................
Type……………………………………………………………………………………
Proposed position……………………...……………………………………………….
2. PERSONAL INFORMATION
a) Surname........................... Other Names ..........................................................

b) Previous Names (if any) by which you have been known:
.......................................................................................................
.......................................................................................................
Reasons for change of names………………………...………….
c) Year and Place of birth: .................................................................

d) Nationality and how acquired….………………….........................
e) Personal Identification Number (PIN) ………................................
f) (i) Identification Card number and date of issue …............................
(ii) Passport number, place and date of issue………………………...
g) Postal Address: …………………….................................................
h) Physical Address.........................................................................
i) Telephone numbers…………...……….………………………….
Educational Qualifications
Qualifications Year Examining Grade Obtained
Obtained Body
1.
2.
3.
1
Professional Qualifications and years obtained
Qualifications Year Examining Grade Obtained
Obtained Body
1.
2.
3.
h) Name(s) of your bankers during the last 5 years

..........................................................................................
..........................................................................................
..........................................................................................
i) Responsibilities of Proposed position
3. EMPLOYMENT/ BUSINESS RECORD
Period Name of Position Held Responsibilities Reasons for

Employer/ & Dates Leaving
Business (where
and applicable)
2
4. DESCRIPTION OF PAST AND PRESENT ACTIVITIES IN KENYA AND
ABROAD
4.1 SHAREHOLDING (DIRECTLY OWNED OR THROUGH NOMINEES)
Company’s Certificate of Number of % of Shareholding Name and

Name registration No. Shares held address of
Beneficial Owner
of shares
4.2 DIRECTORSHIPS
Company’s Certificate Executive or Position Date of Reasons for

Name of Nonexecutive held appointment leaving
registration
No.
4.3 MEMBERSHIP TO PROFESSIONAL BODIES
Name of the Membership Position held Current status Reasons for

institution No. of membership leaving
3
5. BORROWINGS
5.1 Have you ever defaulted in your financial obligations in the last five
years?.......................................................................................................................
.......
If yes, give details
……………………………………………………………………………………
5.2 Have you at any time been convicted of any criminal offence in any jurisdiction?
If so, give particulars of the court in which you were convicted, the offence, the
penalty imposed and the date of conviction
……………………...............................................................................................
……………………………………………………………………………………
5.3 Have you ever been disqualified, under any legislation or regulation from acting
as a director or serving in a managerial capacity?
………………………………………………………………………….......…..
…………………………………………………………………………………..
5.4 Have you, in any country, ever been dismissed from any office or employment,
or been asked to resign or resigned from employment or position of trust or
fiduciary appointment? If so give particulars
.................................................................................................................................
.................................................................................................................................
5.5 Have you ever been diagnosed as being mentally unfit or of unsound mind?
…................................……...……………………….……………………………
…………………………..………………………………………………………..
5.6 Have you ever been adjudged bankrupt?

……………………………………………
If so, give particulars

…………………………...........................................................………………….
……………………………………………………………………………………
4
5.7 Have you ever been convicted of fraud or theft by a court of law in any country?
If so, give particulars

…………………………..........................................................…………...............
5.8 Has any entity with which you were associated as a director, shareholder or
manager in any country been in financial distress, made any compromise or
arrangement with its creditors, been wound up or otherwise ceased business either
while you were associated with it or within three year after you ceased to be
associated with it?
If so, give particulars.………………………………………................................
……………………….............................................……………………………..
……………………………………………………………………………………
5.9 Indicate the names, postal and e-mail addresses, telephone numbers and positions
of at least 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.
Name of Referee Postal E-mail Tel no. (s) Position Relationship

Address address (where with
applicable) applicant
5.10 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
……………………………………………………………………………………
5
6. DECLARATION
I am aware that it is an offence to knowingly provide any information, which is false or

misleading. I am also aware that omitting material information intentionally shall be
construed to be an offence.
I certify that the information given above is complete and accurate to the best of my
knowledge, and that there are no other facts relevant to this application of which the Bank
should be aware.
I undertake to inform the Bank of any material changes to the information provided herein
NAME........……………...................... POSITION HELD

……………………..............................
DATED........…………….…............ AT.................. THIS DAY OF………….................…
SIGNED........…………............................................................................................................
(Applicant)
(This declaration must be signed in the presence of the witness named below)
WITNESSED BEFORE ME:
COMMISSIONER FOR OATHS/MAGISTRATE
Name: …………………..................................................................
Signature: ……………......................................................................
Address: ………………....................................................................
Date and Stamp: ……………………………………………………………
6
N.B. The information given in response to this questionnaire shall be kept confidential
by the supervisory authorities, except in cases provided for by law.
……………………………………….............................................

Form CBK DCP 2

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FORM CBK DCP 2 (Regulations 4 and 7)

1. DIGITAL CREDIT PROVIDER

a) Surname........................... Other Names ..........................................................

c) Year and Place of birth: .................................................................

h) Name(s) of your bankers during the last 5 years

i) Responsibilities of Proposed position

3. EMPLOYMENT/ BUSINESS RECORD

Period Name of Position Held Responsibilities Reasons for

4.1 SHAREHOLDING (DIRECTLY OWNED OR THROUGH NOMINEES)

Company’s Certificate of Number of % of Shareholding Name and

Company’s Certificate Executive or Position Date of Reasons for

4.3 MEMBERSHIP TO PROFESSIONAL BODIES

Name of the Membership Position held Current status Reasons for

5.6 Have you ever been adjudged bankrupt?

If so, give particulars

If so, give particulars

Name of Referee Postal E-mail Tel no. (s) Position Relationship

I am aware that it is an offence to knowingly provide any information, which is false or

NAME........……………...................... POSITION HELD

DATED........…………….…............ AT.................. THIS DAY OF………….................…

WITNESSED BEFORE ME:

COMMISSIONER FOR OATHS/MAGISTRATE

Date and Stamp: ……………………………………………………………

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