Form 33-109F7
REINSTATEMENT OF REGISTERED INDIVIDUALS AND PERMITTED INDIVIDUALS
(sections 2.3 and 2.5(2))

GENERAL INSTRUCTIONS

              Complete and submit this form to the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-regulatory organization (SRO) if an individual has left a sponsoring firm and is seeking to reinstate their registration in one or more of the same categories or reinstate their same status of permitted individual as before with a sponsoring firm. You only need to complete and submit one form regardless of the number of registration categories or permitted individual statuses you are seeking to be reinstated in.

An individual may reinstate their registration or permitted individual status by submitting this form. This form may only be used if all of the following apply:

1.           this form is submitted on or before the 90th day after the cessation date of the individual's employment, partnership or agency relationship with the individual's former sponsoring firm,

2.           there have been no changes to the information previously submitted in respect of Items 13 (Regulatory Disclosure), other than changes to Item 13.3(a), 14 (Criminal Disclosure), 15 (Civil Disclosure) and 16 (Financial Disclosure) of the individual's Form 33-109F4 since the individual left their former sponsoring firm, and

3.           the individual's employment, partnership or agency relationship with their former sponsoring firm did not end because the individual was asked by the firm to resign, resigned voluntarily or was dismissed, following an allegation against the individual of criminal activity, a breach of securities legislation, or a breach of the rules of an SRO.

If you do not meet all of the above conditions then you must apply for reinstatement by completing on NRD a Form 33-109F4 by making the NRD submission entitled 'Reactivation of Registration'.

Terms

In this form, "you", "your" and "individual" means the individual who is seeking to reinstate their registration or their status as permitted individual.

"former sponsoring firm" means the registered firm where you most recently carried out duties as a registered or permitted individual.

"major shareholder" and "shareholder" mean a shareholder who, in total, directly or indirectly owns voting securities carrying 10 per cent or more of the votes carried by all outstanding voting securities.

"new sponsoring firm" means the registered firm where you will begin carrying out duties as a registered or permitted individual when your registration or permitted individual status is reinstated.

Several terms used in this form are defined in the Form 33-109F4 Registration of Individuals and Review of Permitted Individuals that you submitted when you first became registered.

How to submit this form

NRD format

Submit this form at the National Registration Database (NRD) website in NRD format at www.nrd.ca. If you have any questions, contact the compliance, registration or legal department of the new sponsoring firm or a legal adviser with securities law experience, or visit the NRD information website at www.nrd-info.ca.

Format, other than NRD format

If you are relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database, you may submit this form in a format other than NRD format.

If you need more space, use a separate sheet of paper. Clearly identify the Item and question number. Complete and sign the form, and send it to the relevant regulator(s) or, in Québec, the securities regulatory authority, SRO (s) or similar authority. The number of originally signed copies of the form you are required to submit depends on the province or territory, and on the regulator, the securities regulatory authority or SRO.

To avoid delays in processing this form, be sure to answer all of the items that apply to you. If you have questions, contact the compliance, registration or legal department of the new sponsoring firm or a legal adviser with securities law experience, or visit the National Registration Database information website at www.nrd-info.ca.

Item 1    Name

1. NRD number: ______________________________________
2. Legal name

______________________________________________________________________________
Last name	First name	Second name (N/A □)	Third name (N/A □)

3. Date of birth (YYYY/MM/DD):
4. Use of other names

Are you currently using, or have you ever used, operated under, or carried on business under, a name other than the name(s) mentioned above (for example, trade names for sole proprietorships or team names)?

Yes        □           No       □

If "Yes", complete Schedule A.

Item 2    Number of jurisdictions

1. Are you seeking to reinstate your registration or permitted individual status in more than one jurisdiction of Canada?

Yes        □           No       □

2. Check each province or territory in which you are seeking reinstatement of registration or reinstatement as a permitted individual:

□           All jurisdictions

□           Alberta

□           British Columbia

□           Manitoba

□           New Brunswick

□           Newfoundland and Labrador

□           Northwest Territories

□           Nova Scotia

□           Nunavut

□           Ontario

□           Prince Edward Island

□           Québec

□           Saskatchewan

□           Yukon

Item 3    Individual categories

1. On Schedule B, check each category for which you are seeking to reinstate your registration or permitted individual status. If you are seeking reinstatement of status as a permitted individual, check each category that describes your position with your new sponsoring firm.
2. If you are seeking reinstatement as a representative of a mutual fund dealer or of a scholarship plan dealer in Québec, are you covered by your new sponsoring firm's professional liability insurance?

Yes        □           No       □

If "No", state:

The name of your insurer __________________________________________

Your policy number _______________________________________________

Item 4    Address and agent for service

1. Address for service

You must have one address for service in each province or territory where you are submitting this form. A residential or business address is acceptable. A post office box is not acceptable. Complete Schedule C for each additional address for service you are providing.

Address for service:

____________________________________________________________________________

(number, street, city, province or territory, postal code)

Telephone number ___________________________

Fax number, if applicable ___________________________

Business e-mail address ___________________________

2. Agent for service

If you have appointed an agent for service, provide the following information for the agent in each province or territory where you have an agent for service. The address of your agent for service must be the same as the address for service above. If your agent for service is not an individual, provide the name of your contact person.

Name of agent for service: ______________________________________________

Contact person: _______________________________________________________

Last name, First name

Item 5    Location of employment

1. Provide the following information for your new sponsoring firm. If you will be working out of more than one business location, provide the following information for the business location out of which you will be doing most of your business. If you are only filing this form because you are a permitted individual and are not employed by, or acting as agent for, the sponsoring firm, select "N/A".

Unique Identification Number (optional):___________________________

NRD location number: ___________________________

Business location address: _________________________________________________________

(number, street, city, province, territory or state, country, postal code)

Telephone number: (_____) ________________ Fax number: (_____) ________________

N/A        □

2. If the new sponsoring firm has a foreign head office, and/or you are not a resident of Canada, provide the address for the business location in which you will be conducting most of your business. If you are only filing this form because you are a permitted individual and are not employed by, or acting as agent for, the sponsoring firm, select "N/A".

Business location address: _________________________________________________________

(number, street, city, province, territory or state, country, postal code)

Telephone number: (_____) ________________ Fax number: (_____) ________________

N/A        □

[The following under #3 "Type of business location", #4 and #5 is for a Format other than NRD format only]

3. Type of business location:

□           Head office

□           Branch or business location

□           Sub-branch (Mutual Fund Dealers Association of Canada members only)

4. Name of supervisor or branch manager:___________________________
5. □           Check here if the mailing address of the business location is the same as the business location address provided above. Otherwise, complete the following:

Mailing address: ____________________________________________________________

(number, street, city, province, territory or state, country, postal code)

Item 6    Previous employment

Provide the following information for your former sponsoring firm.

Name: ____________________________________________________________________

Date on which you were no longer authorized to act on behalf of your former sponsoring firm as a registered individual or permitted individual: ____________________

(YYYY/MM/DD)

The reason why you left your former sponsoring firm:

____________________________________________________________________________

Item 7    Current employment, other business activities, officer positions held and directorships

Name of your new sponsoring firm:________________________________________

Complete a separate Schedule D for each of your current business and employment activities, including employment and business activities with your new sponsoring firm and any employment and business activities outside your new sponsoring firm. Also include all officer or director positions and any other equivalent positions held, as well as positions of influence. The information must be provided

•             whether or not you receive compensation for such services, and

•             whether or not any such position is business related.

Item 8    Ownership of securities in new sponsoring firm

Are you a partner or major shareholder of your new sponsoring firm?

Yes        □           No       □

If "Yes", complete Schedule E.

Item 9    Confirm permanent record

1. Check the appropriate box to indicate that, since leaving your former sponsoring firm, there has been a change to any information previously submitted for the items of your Form 33-109F4 that are listed below.

□           Regulatory disclosure (Item 13, other than changes to Item 13.3(a))

□           Criminal disclosure (Item 14)

□           Civil disclosure (Item 15)

□           Financial disclosure (Item 16)

2. Check the box below - I am eligible to file this Form 33-109F7, only if you satisfy both of the following conditions:

(a)          there are no changes to any of the disclosure items under Item 9.1 above, and

(b)          your employment, partnership or agency relationship with your former sponsoring firm did not end because you were asked by the firm to resign or resigned voluntarily, or were dismissed, following an allegation against you of

•             criminal activity,

•             a breach of securities legislation, or

•             a breach of the rules of an SRO.

If you do not meet the above conditions for selecting the box ‘I am eligible to file this Form 33-109F7’, then you must apply for reinstatement by completing on NRD a Form 33-109F4 by making the NRD submission entitled "Reactivation of Registration". If you are submitting a Form 33-109F4 in a format other than NRD format you must complete the entire form.

□           I am eligible to file this Form 33-109F7.

Item 10  Acknowledgements, submission to jurisdiction and notice of collection and use of personal information

By submitting this form, you:

•             acknowledge that the submission to jurisdiction, consent to collection and use of personal information, and authorization in respect of SROs (to the extent applicable) that you provided in your Form 33-109F4 remain in effect and extend to this form

•             consent to the collection and disclosure of your personal information by regulators and by your sponsoring firm, in each case, for registration and other related regulatory purposes.

If you have any questions about the collection and use of your personal information, contact the securities regulatory authority or applicable SRO in the relevant jurisdiction. See Schedule F for details. In Québec, you can also contact the Commission d'accès à l'information at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca.

You acknowledge and agree that if you are seeking reinstatement of your registration and it was subject to any undischarged terms and conditions when you left your former sponsoring firm, those terms and conditions will remain in effect at your new sponsoring firm.

Item 11  Warning

It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.

Item 12  Certification

1. Certification - NRD format:

I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm. To the best of my knowledge, the officer, branch manager or supervisor was satisfied that I fully understood the questions. I will limit my activities to those permitted by my category of registration. If the business location specified in this form is a residence, I hereby give my consent for the regulator or, in Québec, the securities regulatory authority to enter that residence for the administration of securities legislation and derivatives legislation, including commodity futures legislation.

□           I am making this submission as agent for the individual. By checking this box, I certify that the individual provided me with all of the information on this form and the certification above.

2. Certification - Format other than NRD format:

Individual

By signing below, I certify to the regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form, either directly or through the principal regulator that:

•             I have read the form and understand the questions,

•             all of the information provided on this form is true, and complete, and

•             if the business location specified in this form is a residence, I hereby give my consent for the regulator or, in Québec, the securities regulatory authority to enter that residence for the administration of securities legislation and derivatives legislation, including commodity futures legislation.

Signature of individual ____________________ Date signed ______________________

(YYYY/MM/DD)

Authorized partner or officer of the new sponsoring firm

By signing below, I certify to the regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form for the individual that:

•             the individual will be engaged by the new sponsoring firm as a registered individual or a permitted individual

•             I have, or a branch manager or another officer or supervisor has, discussed the questions set out in this form with the individual and, to the best of my knowledge, the individual fully understands the questions, and

•             the new sponsoring firm understands that if the individual's reinstatement of registration was subject to any undischarged terms and conditions when the individual left their former sponsoring firm, those terms and conditions remain in effect and agrees to assume any ongoing obligations that apply to the sponsoring firm in respect of the individual under those terms and conditions.

Name of firm ______________________________________________________________

Name of authorized signing officer or partner _____________________________________

Title of authorized signing officer or partner  ______________________________________

Signature of authorized signing officer or partner __________________________________

Date signed _____________________

(YYYY/MM/DD)

 

 

Schedule A
Use of other names (Item 1.4)

Item 1.4               Use of other names

Name 1:

Name: ___________________________________________________________________

Provide the reasons for the use of this other name (for example, trade name or team name):

_____________________________________________________________________________

If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?

Yes        □           No     □

When did you use this name?	From:	To:
	__________________________________
	(YYYY/MM)	(YYYY/MM)

Name 2:

Name: ___________________________________________________________________

Provide the reasons for the use of this other name (for example, trade name or team name):

_____________________________________________________________________________

If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?

Yes        □           No     □

When did you use this name?	From:	To:
	__________________________________
	(YYYY/MM)	(YYYY/MM)

Name 3:

Name: ___________________________________________________________________

Provide the reasons for the use of this other name (for example, trade name or team name):

_____________________________________________________________________________

If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?

Yes        □           No     □

When did you use this name?	From:	To:
	__________________________________
	(YYYY/MM)	(YYYY/MM)

 

 

 

Schedule B
Individual Categories (Item 3)

Check each category for which you are seeking reinstatement of registration, approval or permitted individual status

Categories Common to all jurisdictions under securities legislation

Firm categories [Format other than NRD format only]

[ ] Investment Dealer

[ ] Mutual Fund Dealer

[ ] Scholarship Plan Dealer

[ ] Exempt Market Dealer

[ ] Restricted Dealer

[ ] Portfolio Manager

[ ] Restricted Portfolio Manager

[ ] Investment Fund Manager

Individual categories and permitted activities

[ ] Dealing Representative

[ ] Advising Representative

[ ] Associate Advising Representative

[ ] Ultimate Designated Person

[ ] Chief Compliance Officer

[ ] Permitted Individual as described in paragraph (c) of the definition of "permitted individual" in section 1.1 of National Instrument 33-109 Registration Information

[ ] Officer – Specify title:

[ ] Director

[ ] Partner

[ ] Shareholder

[ ] Branch Manager (MFDA members only)

[ ] IIROC approval only

IIROC

Approval categories

[ ] Executive

[ ] Director (Industry)

[ ] Director (Non-Industry)

[ ] Supervisor

[ ] Investor

[ ] Registered Representative

[ ] Investment Representative

[ ] Trader

Additional approval categories

[ ] Chief Compliance Officer

[ ] Chief Financial Officer

[ ] Ultimate Designated Person

Products

[ ] Non-Trading

[ ] Securities

[ ] Options

[ ] Futures Contracts and Futures Contract Options

[ ] Mutual Funds only

Customer type

[ ] Retail

[ ] Institutional

[ ] Not Applicable

Portfolio management

[ ] Portfolio Management

Categories under local commodity futures and derivatives legislation

Ontario

Firm categories

[ ] Commodity Trading Adviser

[ ] Commodity Trading Counsel

[ ] Commodity Trading Manager

[ ] Futures Commission Merchant

Individual categories and permitted activities

[ ] Advising Representative

[ ] Salesperson

[ ] Branch Manager

[ ] Officer – Specify title:

[ ] Director

[ ] Partner

[ ] Shareholder

[ ] IIROC approval only

Manitoba

Firm categories

[ ] Dealer (Merchant)

[ ] Dealer (Futures Commission Merchant)

[ ] Dealer (Floor Broker)

[ ] Adviser

[ ] Local

Individual categories and permitted activities

[ ] Floor Broker

[ ] Salesperson

[ ] Branch Manager [ ] Adviser

[ ] Officer – Specify title

[ ] Director

[ ] Partner

[ ] Futures Contracts Portfolio Manager

[ ] Associate Futures Contracts Portfolio Manager

[ ] IIROC approval only

[ ] Local

Québec

Firm categories

[ ] Derivatives Dealer

[ ] Derivatives Portfolio Manager

Individual categories and permitted activities

[ ] Derivatives Dealing Representative

[ ] Derivatives Advising Representative

[ ] Derivatives Associate Advising Representative

 

 

Schedule C
Address and agent for service (Item 4)

Item 4.1               Address for service

You must have one address for service in each province or territory in which you are now, or are seeking to become, a registered individual or permitted individual. A post office box is not an acceptable address for service.

Address for service:

____________________________________________________________________________

(number, street, city, province or territory, postal code)

Telephone number: (___) __________________ Fax number: (___) ______________________

Business e-mail address:___________________________

Item 4.2               Agent for service

If you have appointed an agent for service, provide the following information for the agent. The address for service provided above must be the address of the agent named below.

Name of agent for service: ______________________________________________

(if applicable)

Contact person:

___________________________________________________________________

Last name, First name

 

 

Schedule D
Current employment, other business activities, officer positions held and directorships (Item 7)

Complete a separate Schedule D for each of your current business and employment activities, including employment and business activities with your new sponsoring firm and any employment and business activities outside your new sponsoring firm. Also include all officer or director positions and any other equivalent positions held, as well as positions of influence. The information must be provided

•             whether you receive compensation for such services, and

•             whether or not such position is business related.

1. Start date

_____________________

(YYYY/MM/DD)

2. Firm information

□           Check here if this activity is employment with your sponsoring firm.

If the activity is with your sponsoring firm, you are not required to indicate the firm name and address information below:

Name of business or employer: ______________________________________

_______________________________________________________________

Address of business or employer:

_______________________________________________________________

(number, street, city, province, territory or state, country)

Name and title of your immediate supervisor: ___________________________

3. Description of duties

Describe all employment and business activities related to this employer. Include the nature of the business and your duties, title or relationship with the business. If you are seeking registration that requires specific experience, include details such as level of responsibility, value of accounts under direct supervision, number of years of experience, and percentage of time spent on each activity.

________________________________________________________

4. Number of work hours per week

How many hours per week do you devote to this business or employment?

________________

If this activity is employment with your sponsoring firm and you work less than 30 hours per week, explain why.

________________________________________________________

5. Conflict of Interest

If you have more than one employer or are engaged in business related activities:

A. Disclose any potential for confusion by clients and any potential for conflicts of interest arising from your multiple employment or business related activities or proposed business related activities.

________________________________________________________

________________________________________________________

________________________________________________________

B. Indicate whether or not any of your employers or organizations where you engage in business related activities are listed on an exchange.

________________________________________________________

________________________________________________________

________________________________________________________

C. Confirm whether the firm has procedures for minimizing potential conflicts of interest and if so, confirm that you are aware of these procedures.

________________________________________________________

________________________________________________________

________________________________________________________

D. State the name of the person at your sponsoring firm who has reviewed and approved your multiple employment or business related activities or proposed business related activities.

________________________________________________________

________________________________________________________

________________________________________________________

E. If you do not perceive any conflicts of interest arising from this employment, explain why.

________________________________________________________

________________________________________________________

________________________________________________________

 

 

Schedule E
Ownership of securities in new sponsoring firm (Item 8)

Firm name (whose business is trading in or advising on securities or derivatives, or both):

_________________________________________________

What is your relationship to the firm?        Partner □            Major shareholder □

What is the period of this relationship?

From:	To:	(if applicable)
_________________	_________________
(YYYY/MM)	(YYYY/MM)

Provide the following information:

a)           State the number, value, class and percentage of securities, or the amount of partnership interest you own or propose to acquire when you are reinstated or approved as a result of the review of this form. If acquiring shares when you are so approved or registered, state the source (for example, treasury shares, or if upon transfer, state name of transferor).

_____________________________________________________________________

b)           State the market value (approximate, if necessary) of any subordinated debentures or bonds of the firm to be held by you or any other subordinated loan to be made by you to the firm:

_____________________________________________________________________

c)           If another person or firm has provided you with funds to invest in the firm, provide the name of the person or firm and state the relationship between you and that person or firm:

_____________________________________________________________________

d)           Are the funds to be invested (or proposed to be invested) guaranteed directly or indirectly by any person or firm?

Yes        □           No     □

If "Yes", provide the name of the person or firm and state the relationship between you and that person or firm: ______________________________________________________

e)           Have you directly or indirectly given up any rights relating to these securities or this partnership interest, or do you, when you are registered or approved as a result of the review of this form, intend to give up any of these rights (including by hypothecation, pledging or depositing as collateral the securities or partnership interest with any firm or person)?

Yes        □           No     □

If "Yes", provide the name of the person or firm, state the relationship between you and that person or firm and describe the rights that have been or will be given up:________________________________

f)            Is a person other than you the beneficial owner of the shares, bonds, debentures, partnership units or notes held by you?

Yes        □           No     □

If "Yes", complete (g), (h) and (i).

g)           Name of beneficial owner:

_______________________________________________________________________

Last name

First name

Second name (N/A □)

Third name (N/A □)

h)           Residential address:

____________________________________________________________________

(number, street, city, province, territory or state, country, postal code)

i)            Occupation: __________________________________________

 

 

Schedule F
Contact information for Notice of collection and use of personal information

Alberta Alberta Securities Commission Suite 600, 250–5th St. SW Calgary, AB T2P 0R4 Attention: Information Officer Telephone: (403) 297-6454	Nunavut Government of Nunavut Department of Justice P.O. Box 1000 Station 570 Iqaluit, NU X0A 0H0 Attention: Superintendent of Securities Telephone: (867) 975-6590
British Columbia British Columbia Securities Commission P.O. Box 10142, Pacific Centre 701 West Georgia Street Vancouver, BC V7Y 1L2 Attention: Freedom of Information Officer Telephone: (604) 899-6500 or (800) 373-6393 (in Canada)	Ontario Ontario Securities Commission 22nd Floor 20 Queen Street West Toronto, ON M5H 3S8 Attention: Compliance and Registrant Regulation Telephone: (416) 593-8314 e-mail: [email protected]
Manitoba The Manitoba Securities Commission 500 - 400 St. Mary Avenue Winnipeg, MB R3C 4K5 Attention: Director of Registrations Telephone: (204) 945-2548 Fax: (204) 945-0330	Prince Edward Island Securities Office Department of Community Affairs and Attorney General P.O. Box 2000 Charlottetown, PE C1A 7N8 Attention: Superintendent of Securities Telephone: (902) 368-6288
New Brunswick Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick Suite 300, 85 Charlotte Street Saint John, NB E2L 2J2 Attention: Registration Telephone: (506) 658-3060	Québec Autorité des marchés financiers 800, square Victoria, 22e étage C.P. 246, tour de la Bourse Montréal (Québec) H4Z 1G3 Attention: Responsable de l'accès à l'information Telephone: (514) 395-0337 or (877) 525-0337
Newfoundland and Labrador Superintendent of Securities, Service NL Government of Newfoundland and Labrador P.O. Box 8700 2nd Floor, West Block Confederation Building St. John's, NL A1B 4J6 Attention: Manager of Registrations Telephone: (709) 729-5661	Saskatchewan Financial and Consumer Affairs Authority of Saskatchewan Suite 601, 1919 Saskatchewan Drive Regina, SK S4P 4H2 Attention: Deputy Director, Capital Markets Telephone: (306) 787-5871
Nova Scotia Nova Scotia Securities Commission Suite 400, 5251 Duke Street Halifax, NS B3J 1P3 Attention: Deputy Director, Capital Markets Telephone: (902) 424-7768	Yukon Government of Yukon Superintendent of Securities Department of Community Services P.O. Box 2703 C-6 Whitehorse, YT Y1A 2C6 Attention: Superintendent of Securities Telephone: (867) 667-5314
Northwest Territories Government of the Northwest Territories Department of Justice 1st Floor Stuart M. Hodgson Building 5009 – 49th Street Yellowknife, NWT X1A 2L9 Attention: Deputy Superintendent of Securities Telephone: (867) 920-8984	Self-regulatory organization Investment Industry Regulatory Organization of Canada 121 King Street West, Suite 2000 Toronto, Ontario M5H 3T9 Attention: Privacy Officer Telephone: (416) 364-6133 E-mail: [email protected]