WorldQuant, LLC

WebSim Consultant
Questionnaire

For Russia, India, Israel, Malaysia,

Indonesia & Thailand

April 2019: V3

Copyright © 2019 WorldQuant, LLC. All Rights Reserved. COMMERCIAL

SECRET. THIS DOCUMENT CONTAINS CONFIDENTIAL AND
PROPRIETARY INFORMATION OF WORLDQUANT, LLC.
 WebSim CONSULTANT QUESTIONNAIRE

All information must be true and complete to the best of your knowledge and belief. All information provided in
this form is subject to verification by WorldQuant, LLC (the “Firm”) and/or its agents, and any falsification,
misrepresentation or omission of fact in this form, or during the engagement process, may be cause for denial or
termination of your or your firm’s consulting agreement with the Firm. Responses to various questions
contained in this questionnaire (including, without limitation, the questions set forth in Appendix A hereto) are
required in connection the Firm’s obligations under the U.S. Investment Advisers Act of 1940, as amended and
the U.S. Securities Act of 1933, as amended.

I. GENERAL BACKGROUND

First Name: ___________________ Middle Name: _________________ Last Name: ____________________

List any other names (including shortened versions, e.g., nicknames) under which you are known or have done
business:

Current Home Address:

Please provide complete address history for the past five years. Please attach additional sheets if necessary.

Address Dates (month/year)

From To

Contact Information:
Day #: ___________________ Eve #: ___________________ Cell #: ___________________

Please indicate whether we should be cautious about reaching you at any of the above numbers (e.g., current work number):

___________________________________________________________________________________________________

Personal E-mail Address: ___________________________________________________________________

Are you at least 18 years of age? Yes No

Have you been a student with WorldQuant University within the past 12 months? Yes No

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
II. EMPLOYMENT HISTORY

Please provide current employer information or Most Recent Employer.

Current or Most Recent Employer

If you do not wish us to contact your current employer please check here

Is there someone within the organization we may call for a reference?

Name

Title

Relationship to you

Company Dates From To

(month/year)

Position held Department

If you are not an employee of the company, provide the name of the agency or consulting firm by which you are employed.

Please list employer’s information below. Note: If you are employed by an agency or consulting firm, provide the information below.

Address

City, State, Country, Zip Code

Telephone Fax

Main responsibilities

Manager name

Manager contact information

Additional reference within organization

Additional reference contact information

Reason for leaving

Resignation Termination/Dismissal Redundancy/layoff
End of contract Retirement Other (specify)

*Do not include overtime, profit sharing, etc.

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
Have you accepted any offer for an internship and/or full-time employment which internship or employment has
not yet commenced? Yes No

If Yes, please provide the name of the organization or employer from whom you received such offer and the
date of commencement of the internship or employment.

III. OUTSIDE AFFILIATIONS

I am (a) an officer or director of a company whose shares are publicly traded, or (b) the owner of 10% or more of
any class of equity security in a company whose shares are publicly traded. Yes No

I have a direct or indirect financial interest in, or make investment decisions over, the account of another person
who is (a) an officer or director of a company whose shares are publicly traded, or (b) the owner of 10% or more
of any class of equity security in a company whose shares are publicly traded. Yes No

If yes to either question above, please identify the company name and your interest in or position at the
company. Please attach additional sheets if necessary.

Company name Relationship

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
IV. OUTSIDE BUSINESS ACTIVITIES

Do you currently engage in any outside business activities? Yes No

If yes, please disclose all outside business activities in which you engage, whether or not such work is
for compensation. You do not need to disclose activity that is exclusively charitable, civic, religious or
fraternal, and is recognized as tax exempt unless the activity requires you to exercise investment discretion,
occupies a substantial portion of your time or if you have primary responsibility for that organization or affiliation.
Please include trustee/director positions in family organizations in which you exercise direct or indirect
investment authority. Attach additional sheets if necessary.

Company name & address Type of Position/Duties Hours spent How long have you
business per month engaged in such
/service (Total and during activity?
securities trading
hours) From To

Are any of the business activities investment-related (i.e., pertain to securities, commodities, banking, insurance,
or real estate, including, but not limited to, acting as or being associated with a broker-dealer, issuer, investment
company, investment adviser, futures sponsor, bank or savings association?) Yes No

V. HOUSEHOLD MEMBERS/RELATIVES IN FINANCIAL SERVICES INDUSTRY

Do any members of your household or relatives (a) serve as directors or officers of public companies, (b) hold
positions in the securities industry or provide services to the securities industry (include managers of family,
charitable or other investment funds) or (c) hold positions in businesses that are related to your trading sector?
Yes No

If yes, please disclose the name, position, and company of household member or relative. Please attach
additional sheets if necessary.
Name Position/Company Relationship to you

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
VI. RESTRICTIONS AFFECTING YOUR ABILITY TO PROVIDE CONSULTING
SERVICES TO THE FIRM

Are you a subject to, or would your proposed consulting agreement with the Firm potentially violate, a
confidentiality, non-disclosure, non-competition, non-solicitation or garden-leave agreement? Yes No
If yes, identify: (a) the counterparty to the agreement, (b) a brief description of the subject matter covered by the
agreement, (c) and the date the agreement was entered into (if possible, please provide copy of agreement):
Counterparty Brief description Date of agreement Copy provided?

Do you possess or have access to information that may be considered confidential or nonpublic concerning any
public issuer? Yes No
Inside information is material, non-public information about a security. Non-public means the information has
not been disseminated through a recognized channel or distribution. Material means any reasonable
shareholder would consider the information important in making an investment decision regarding the security.
If you have access to such potentially material, non-public information due to your current position in your firm or
company, you must answer “yes” to this item.

If yes to question above, please explain:

Have you served on a creditors committee in the last year? Yes No

If yes, please provide the name of the debtor and the dates of your service:

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
VII. RESUME

Please attach a copy of your most recent resume.

VIII. PERSONAL STATEMENT

(Please read carefully and sign below to indicate acceptance.)

I certify that the information provided in this form is true and complete to the best of my knowledge and belief. I
understand that all information provided in this form is subject to verification by the Firm and/or its agents, and
that any falsification, misrepresentation or omission of fact in this form, or during the engagement process, may
be cause for refusal or termination (or my agency’s consulting agreement) with the Firm.

I acknowledge that any Firm information or material not generally known to the public that I may obtain
through the engagement process or through my affiliation with the Firm must not be shared, transferred or
distributed in any way.

Personal Data Processing

I hereby consent to my personal information being stored (in any format) and (or) processed by the Firm, and
(or) transferred (including cross-border transfer) to its subsidiaries or to the Firm's third party service providers,
as required for the purposes of my prospective consultancy with the Firm (or its subsidiary).

Print Name: __________________________________

Signature: ___________________________________ Date: ____________________________________

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
APPENDIX A
REGULATORY QUESTIONS – For “yes” answers to the following questions, please provide details on a
separate page:

YES NO
A. In the past ten years, have you:
(1) been convicted of or pled guilty or nolo contendere (“no contest”) in a domestic, foreign, or
military court to any felony?
(2) been charged with any felony?
Note: A conviction record will not necessarily disqualify you from being retained as a consultant.
It will be considered only as it may relate to the job you are seeking. Factors such as your age at
the time of the offense, the seriousness and nature of the offense, and rehabilitation will also be
taken into account.
YES NO
B. In the past ten years, have you:

(1) been convicted of or pled guilty or nolo contendere (“no contest”) in a domestic, foreign, or
military court to a misdemeanor involving: investments or an investment-related business,
or any fraud, false statements, or omissions, wrongful taking of property, bribery, perjury,
forgery, counterfeiting, extortion, or a conspiracy to commit any of these offenses?
(2) been charged with a misdemeanor listed in question B(1) above?

YES NO
C. Has the SEC or the Commodity Futures Trading Commission (“CFTC”) ever:

(1) found you to have made a false statement or omission?

(2) found you to have been involved in a violation of SEC or CFTC regulations or statutes?
(3) found you to have been a cause of an investment-related business having its authorization to
do business denied, suspended, revoked, or restricted?
(4) entered an order against you in connection with investment-related activity?

(5) imposed a civil money penalty on you, or ordered you to cease and desist from any activity?

YES NO
D. Has any other federal regulatory agency, any state regulatory agency, or any foreign
financial regulatory authority:
(1) ever found you to have made a false statement or omission, or been dishonest, unfair, or
unethical?
(2) ever found you to have been involved in a violation of investment-related regulations or
statutes?
(3) ever found you to have been a cause of an investment-related business having its
authorization to do business denied, suspended, revoked, or restricted?
(4) in the past ten years, entered an order against you in connection with an investment-related
activity?
(5) ever denied, suspended, or revoked your registration or license, or otherwise prevented you,
by order, from associating with an investment-related business or restricted your activity?
YES NO
E. Has any self-regulatory organization or commodities exchange ever:

(1) found you to have made a false statement or omission?

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
 (2) found you to have been involved in a violation of its rules (other than a violation designated
as a “minor rule violation” under a plan approved by the SEC)?
(3) found you to have been the cause of an investment-related business having its authorization
to do business denied, suspended, revoked, or restricted?

(4) disciplined you by expelling or suspending you from membership, barring or suspending you
from association with other members, or otherwise restricting your activities?

YES NO
F. Has an authorization to act as an attorney, accountant, or federal contractor granted to
you ever been revoked or suspended?
YES NO
G. Are you now the subject of any regulatory proceeding that could result in a “yes” answer
to any part of questions C, D or E above?
YES NO
H. (1) Has any domestic or foreign court:

(a) in the past ten years, enjoined you in connection with any investment-related activity?
(b) ever found that you were involved in a violation of investment-related statutes or
regulations?
(c) ever dismissed, pursuant to a settlement agreement, an investment-related civil action
brought against you by a state or foreign financial regulatory authority?
(2) Are you now the subject of any civil proceeding that could result in a “yes” answer to any of
the questions in Section H(1) above?
YES NO
I. In the past 10 years have you been convicted of any felony or misdemeanor:
(1) in connection with the purchase or sale of any security?
(2) involving the making of any false filing with the SEC?
(3) arising out of the conduct of the business of an underwriter, broker, dealer, municipal
securities dealer, investment adviser or paid solicitor of purchasers of securities?
YES NO
J. Are you subject to any order, judgment or decree of any court of competent jurisdiction,
entered in the last 5 years, that restrains or enjoins you from engaging or continuing to
engage in any conduct or practice:
(1) in connection with the purchase or sale of any security?
(2) involving the making of any false filing with the SEC?
(3) arising out of the conduct of the business of an underwriter, broker, dealer, municipal
securities dealer, investment adviser or paid solicitor of purchasers of securities?
YES NO
K. Are you subject to a final order of a state securities commission (or an agency or officer
of a state performing like functions); a state authority that supervises or examines banks,
savings associations, or credit unions; a state insurance commission (or an agency or
officer of a state performing like functions); an appropriate federal banking agency; the
U.S. Commodity Futures Trading Commission; or the National Credit Union
Administration that:
(1) bars you from association with an entity regulated by such commission, authority, agency or
officer?
(2) bars you from engaging in the business of securities, insurance or banking?
(3) bars you from engaging in savings association or credit union activities?
(4) constitutes a final order, entered within the last 5 years, based on a violation of any law or
regulation that prohibits fraudulent, manipulative, or deceptive conduct?

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
 YES NO
L. Are you subject to an order of the SEC 1 that:
(1) suspends or revokes any person’s registration as a broker, dealer, municipal securities
dealer or investment adviser?
(2) places limitations on the activities, functions or operations of such person?
(3) bars such person from being associated with any entity or from participating in offering of
any penny stock?
YES NO
M. Are you subject to any order of the SEC, entered within the last 5 years, that ordered you
to cease and desist from committing or causing a violation or future violation of:
(1) Any scienter-based anti-fraud provision of the federal securities laws 2?
(2) Section 5 of the Securities Act of 1933 (15 U.S.C. 77e)?
YES NO
N. Have you been suspended or expelled from membership in, or suspended or barred from
association with, a member of, a registered national securities exchange or a registered
national or affiliated securities association for any act or omission to act constituting
conduct inconsistent with just and equitable principles of trade?
YES NO
O. Within the past 5 years, have you filed (as a registrant or issuer), or were you named as an
underwriter in any registration statement or Regulation A offering statement filed with the
SEC that was the subject of a refusal order, stop order, or order suspending the
Regulation A exemption, or are you the subject of an investigation or proceeding to
determine whether a stop order or suspension order should be issued?
YES NO
P. Are you subject to a United States Postal Service false representation order entered within
the last 5 years, or are you subject to a temporary restraining order or preliminary
injunction with respect to conduct alleged by the United States Postal Service to
constitute a scheme or device for obtaining money or property through the mail by means
of false representations?

1
Include orders entered pursuant to section 15(b) or 15B(c) of the Securities Exchange Act of 1934 (15 U.S.C. 78o(b) or
78o-4(c)) or section 203(e) or (f) of the Investment Advisers Act of 1940 (15 U.S.C. 80b-3(e) or (f)).
2 These laws include, without limitation, section 17(a)(1) of the Securities Act of 1933 (15 U.S.C. 77q(a)(1)), section 10(b) of
the Securities Exchange Act of 1934 (15 U.S.C. 78j(b)) and 17 CFR 240.10b-5, section 15(c)(1) of the Securities Exchange
Act of 1934 (15 U.S.C. 78o(c)(1)) and section 206(1) of the Investment Advisers Act of 1940 (15 U.S.C. 80b-6(1)), or any
other rule or regulation thereunder.

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
 SUPPLEMENTAL DISCLOSURE QUESTIONS 3

DISCLOSURE QUESTIONS
Customer Complaint/Arbitration/Civil Litigation Disclosure YES NO
Have you ever been named as a respondent/defendant in an investment-related, consumer-
initiated arbitration or civil litigation which alleged that you were involved in one or more
violations alleging false or misleading disclosures or omissions that:
(a) is still pending, or
(b) resulted in an arbitration award or civil judgment against you, regardless of amount?
Termination Disclosure YES NO
Have you ever voluntarily resigned, been discharged or permitted to resign after allegations
were made that accused you of:
(a) violating investment-related statutes, regulations, rules, or industry standards of conduct?
(b) fraud or the wrongful taking of property?
(c) failure to supervise in connection with investment-related statutes, regulations, rules or
industry standards of conduct?

Please provide any additional information (attach additional pages as necessary):

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Subject to the Firm’s obligations under the Investment Advisers Act of 1940 and the rules and regulations thereunder:

• A conviction record will not necessarily disqualify you from engagement. It will be considered only as it may relate to the role you
are seeking. Factors such as your age at the time of the offense, the seriousness and nature of the offense, and rehabilitation will
also be taken into account. Please make sure your explanation for any answer of “yes” is sufficiently informative so that individual
circumstances can be considered. Use additional paper if necessary.
Do not identify any guilty plea that was discharged by the court under the Georgia’s First Offender Act.

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.
APPENDIX B
DISCLOSURE STATEMENT AND AUTHORIZATION
By this document, the Firm discloses to you that a screening, background check, consumer report and/or
investigative consumer report (“Report”) containing information concerning your criminal record, credit record,
character, general reputation, personal characteristics, professional and educational background, and/or mode
of living (“Information”), may be obtained in connection with your application to become a consultant to the Firm
and also may be obtained for any purpose at any time during the term of your consulting agreement with the
Firm. A Report may involve personal interviews with sources such as neighbors, friends, associates or others.
In obtaining a Report, the Firm may review information regarding your conviction record, credit report and/or
driving record (all to the extent allowed under applicable law), and/or receive transcripts, records and/or
documents pertaining to your background, education, prior employment and/or employment performance,
and/or to conduct and obtain the results of any required drug test, which shall only be obtained and conducted in
accordance with applicable law.

By signing below you acknowledge your understanding that as part of the Firm’s background investigation, the
Firm may obtain (including from outside vendors) a Report. You authorize the Firm, or its agents, to request
that any and all of your business associates, landlords, federal, state and/or local government agencies, national
credit bureaus, schools and any other parties furnish Information to the Firm or its agents. Moreover, you hereby
release each such source of Information from any liability whatsoever resulting from the furnishing of such
Information to the Firm or its agents. You further authorize the Firm to make available to any prospective
employer and/or to any federal, state or municipal agency any Information it may have concerning you.

Upon written request, you will be informed whether or not a Report was requested, and if such Report was
requested, the nature and scope of any investigation, and the name and address of the consumer reporting
agency to whom the request was made. You will be able to inspect and receive a copy of such Report by
contacting such agency. If the Firm intends to make an adverse decision regarding your application to become
a consultant to the Firm based, in whole or in part, on any Information from the Report, the Firm will provide you
with a copy of any such Report prior to implementing such action. You acknowledge and agree that this
authorization will remain on file and will serve as a continuing authorization for the Firm to conduct drug and
other controlled substance testing and procure CRD registration records, Reports, or other screening and
background checks, at any time during the term of your consulting agreement with the Firm.

Print full name: __________________________________________________________________________

Signature: ______________________________________________________________________________

Date: ___________________________________________________________________________________

Social Security #: _______--______--_______

Other Identification No.: ___________________________________________________________________

(e.g. NI Number, NRIC, HKID, FIN)

Birth date (including year): _________________________________________________________________

Prior legal name(s) (if any): _________________________________________________________________

Date of name change: _____________________________________________________________________

CRD Number (if any): ______________________________________________________________________

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COMMERCIAL SECRET. Confidential Information of WorldQuant, LLC.