Personal Questionnaire and Declaration Supplement
Personal Questionnaire and Declaration Supplement Personal Questionnaire and Declaration Supplement
Form PQD/SPQDSupplementTo be completed by:__________________________________________Name of Licensee(on behalf of Chief Executive Officer, Controllersand Officers of Insurance Companies)As at December 31, 200__Name of Chief ExecutiveOfficer, Controller,or Officer(Surname first)Relationship toPosition in CompanyDate of Appointmentto Position…………………………………..Company Stamp and Date…………………………………..Corporate Secretary/Director
Form PQD/SPQD<strong>Supplement</strong>To be completed by:__________________________________________Name of Licensee(on behalf of Chief Executive Officer, Controllers<strong>and</strong> Officers of Insurance Companies)As at December 31, 200__Name of Chief ExecutiveOfficer, Controller,or Officer(Surname first)Relationship toPosition in CompanyDate of Appointmentto Position…………………………………..Company Stamp <strong>and</strong> Date…………………………………..Corporate Secretary/Director
Change language