D1 PART D: Declatation


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D1: Part D Declarations

Have you ever been arrested, detained, charged, indicted, convicted, found guilty or been expunged of any offence(s) against the law in any country (Except Minor traffic citations.)?
YesNo
Have you ever testified before a grand jury or investigative hearing or probe?
YesNo
Have any charges, or accusations of illegal activity of any nature been made against you in any country?
YesNo
Have you ever been sentenced to serve a period of time in detention or been in probation?
YesNo
Have you ever had a civil or criminal record expunged or sealed by a court order? Yes /No If yes, give details.
YesNo
Have you ever received a pardon for any criminal offense? (If yes, note Date, City, County, State and Country.)
YesNo
Have you ever been subpoenaed to appear to testify before a federal, state, or county grand jury, board or commission?
YesNo
Has a criminal indictment, information, or complaint ever been returned against you, but for which you were not arrested or in which you were named as an un-indicted co-party?
YesNo
Have you, as an individual, or as an owner, partner, director or officer of any partnership, corporation or other entity, ever been a party to a lawsuit as either a plaintiff or defendant? (Other than divorces).
YesNo
Have you ever been involved, directly or indirectly, in the financing of terrorism or in any terrorist or criminal organization?
YesNo
Have you ever been under investigation by any law enforcement agency or tax authority in any country?
YesNo
Have you ever been involved personally, or as a director in any bankruptcy, insolvency or liquidation?
YesNo
Have you ever been refused an entry visa to, or residency permit in any country, been unlawfully present in, been deported from any country, or sought to assist others to do the same?
YesNo
Have you ever had a visa cancelled?
YesNo
Have you ever applied for citizenship in any country and citizenship has not been granted?
YesNo
Have you ever been the subject of any order, judgment or decree of any federal or state authority barring, suspending, or otherwise limiting your right to engage in any professional or business practice or activity?
YesNo
Have you ever been a senior politician, head of state or government, official of a political party, senior judicial or military official, and/or senior executive of state-owned enterprise?
YesNo


If you have answered yes to any questions ABOVE, please provide with further details:



Please provide the details of two(2) character references who have known you for five (5) years or more. Do not include relatives, present employers or employees:



(1)

Full Name
Street Address
City / State
Country and postal code
Home Phone
Cell Phone / Mobile Number
Email Address
Years Known

Occupation
Employer
Work Phone



(2)

Full Name
Street Address
City / State
Country and postal code
Home Phone
Cell Phone / Mobile Number
Email Address
Years Known

Occupation
Employer
Work Phone