Julian Harris Inter- & Intranet | Supplementary Form

First name

Surname

Email

Telephone

Mobile

1) Please answer the following questions by ticking the appropriate box. If a yes box is ticked, please provide full details on page 6.

		Yes	No
1.1	Have you ever been the subject of any complaint in connection Regulated Investment, Mortgage or General Insurance?
1.2	Have you ever been the subject of any disciplinary action by your current or a previous employer?
1.3	Have you ever not honoured any debts?
1.4	Will there be any other individuals involved in your intended business?
1.5	Do you have existing professional Indemnity Insurance?
1.6	Do you have responsibility for any current or future claims against advice you have given?

2) List all your relevant qualifications

3) Statement of personal assets, liabilities and personal expenditure

Assets	Value	Income (specify)
House(s) and other real property
Investments
Other major assets (specify)

Liabilities	Balance	Monthly Costs
Mortgage(s)
Loan(s)
Credit Card(s)
Debt with previous company(s)

4) Other requirements

	To be downloaded	To be posted
Latest copies of all current accounts (business and personal)
Copies of exams certificates
Sample of intended business stationeries (letterhead and business card)

5) Forecast of income and expenditure in the first 12 months (use a separate sheet of paper if needed or attach a copy of your forecast to this application form)

	Month
Expenditure	1	2	3	4	5	6
1
2
3
4
5
6
7
8
9
10
Balance

	Month
Expenditure	7	8	9	10	11	12
1
2
3
4
5
6
7
8
9
10
Balance

	Month
Income	1	2	3	4	5	6
1
2
3
4
5
6
7
8
9
10
Balance

	Month
Income	7	8	9	10	11	12
1
2
3
4
5
6
7
8
9
10
Balance

6) Brief Business Plan of Action (also state here if working from home or in an office. If office, state the office address and whether it is rented or owned)

7) Notes on Item 1

8) References

Give the names and address of three referees. These should be individuals who have engaged or employed you in the conduct of investment business within the last five years. Where this is not possible, you should provide the name(s) of another person(s)who has experiences of your conduct of investment business. If neither of these is possible, give the name(s) of an individual(s) who has experience of your conduct of business. Starting from most recent.

Contact Person
Company Name
Company Address


Position Held

Contact Person
Company Name
Company Address


Position Held

Contact Person
Company Name
Company Address


Position Held

May JHF/JHM Ltd take up references from your most recent employer now?

Yes	No
If No, please explain

9) Bank Details

Please fill in your bank details for commission payments

Account Name
Account Number
Bank Name
Sort Code

10) Declaration

	I confirm that the details contained herein and accompanying this form are true and shall be the basis of my application to become an Appointed Representative/Company Representative of JHFC/JHM Ltd, and agree to the company taking up any references or making enquiries it deems necessary in considering this application. There are no material facts which may be relevant to my application which have not been disclosed.

	This application is not a binding agreement to join JHFC/JHM Ltd, and I understand that I will not be authorised to give advice under any circumstances until my full authorisation is possible.

	I further confirm that I did not resign and have not been dismissed from any appointment for any reason connected with a breach (or alleged breach) of the Rules of PIA or any other regulatory body.

When you click submit, you will be making a formal application to join Julian Harris network and allow us take up references and run credit checks. Once we have validated the information contained in this application form, we will email you a password that will enable you to complete the recruitment process electronically, one of which is to upload necessary documents.

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