Rule: OSC Rule - 33-506 - Registration Information Requirements

OSC Rule

June 14, 2002

ONTARIO SECURITIES COMMISSION RULE 33-506
(COMMODITY FUTURES ACT)

REGISTRATION INFORMATION

PART 1 DEFINITIONS

1.1 Definitions - In this Rule

"non-registered individual" means, for a registered firm or for a person or company that is applying for registration, an individual who is not registered to trade or advise on behalf of the firm and who

(a) is a director, partner, or officer of the firm, or

(b) beneficially owns, directly or indirectly, or exercises control or direction over, 10 percent or more of the voting securities of the firm;

"Rule 31-509" means Ontario Securities Commission Rule 31-509 (Commodity Futures Act) National Registration Database;

"NRD submission number" means the unique number generated by NRD to identify each NRD submission;

"registered firm" means a person or company that is registered as a dealer or adviser;

"registered individual" means, for a registered firm, an individual who is registered to trade or advise on behalf of the registered firm;

"sponsoring firm" means,

(a) for a registered individual, the registered firm on whose behalf the individual trades or advises,

(b) for an individual applying for registration, the registered firm, or the person or company applying to become a registered firm, on whose behalf the individual proposes to trade or advise,

(c) for a non-registered individual of a registered firm, the registered firm, or

(d) for a non-registered individual of a person or company that is applying for registration, the person or company that is applying for registration.

1.2 Interpretation - Terms defined in Rule 31-509 and used in this Rule have the respective meanings ascribed to those terms in Rule 31-509.

PART 2 APPLICATION FOR REGISTRATION

2.1 Dealer and Adviser Registration - An applicant for registration as a dealer or adviser must submit to the Director

(a) in paper format a completed Form 5;

(b) in accordance with Rule 31-509, a completed Form 33-506F3 for each business location of the applicant, other than the applicant's head office; and

(c) in accordance with Rule 31-509, a completed Form 33-506F4 for each non-registered individual of the applicant who has not applied to become a registered individual with the applicant under subsection 2.2(1).

2.2 Individual Registration

(1) Except as provided in subsection (2), an individual who applies to become a registered individual must make the application by submitting to the Director in accordance with Rule 31-509 a completed Form 33-506F4.

(2) Despite subsection (1), a non-registered individual of a registered firm who applies to become a registered individual with the firm must make the application by submitting to the Director in accordance with Rule 31-509 a completed Form 33-506F2.

PART 3 CHANGES TO REGISTERED FIRM INFORMATION

3.1 Changes to Form 5 Information

(1) A registered firm must notify the Director of a change to any information previously submitted in Form 5, or under this subsection, within 5 business days of the change.

(2) Except as provided in subsection (3), for the purposes of subsection (1), a notice of change must be made by submitting a completed Form 33-506F5 in paper format.

(3) Despite subsection (2), a notice of change under this section is not required to be in Form 33-506F5 if the change relates to

(a) the addition of an officer, partner, or director to the registered firm, and if a completed Form 33-506F4 in respect of the officer, partner, or director is submitted under section 2.2 or 3.3;

(b) the resignation or termination of an officer, partner, or director of the registered firm, and if a completed Form 33-506F1 is submitted under section 4.3 or 5.2; or

(c) a business location other than head office, and if a completed Form 33-506F3 is submitted under section 3.2.

3.2 Changes to Business Locations

(1) A registered firm must notify the Director of the opening of a business location, other than a new head office, by submitting in accordance with Rule 31-509 a completed Form 33-506F3 within 5 business days of the opening.

(2) A registered firm must notify the Director of a change to any information previously submitted in Form 33-506F3 by submitting in accordance with Rule 31-509 a completed Form 33-506F3 within 5 business days of the change.

3.3 Addition of Non-registered Individuals - A registered firm must submit to the Director in accordance with Rule 31-509 a completed Form 33-506F4 for a non-registered individual within 5 business days of the individual becoming a non-registered individual of the registered firm.

PART 4 CHANGES TO REGISTERED INDIVIDUAL INFORMATION

4.1 Changes to Form 33-506F4 Information

(1) Except as provided in subsection (2), a registered individual must notify the Director in accordance with Rule 31-509 of a change to any information previously submitted in Form 33-506F4, or under this subsection, within 5 business days of the change.

(2) Despite subsection (1), a registered individual must notify the Director in accordance with Rule 31-509 of a change to information previously submitted in Item 3 or Item 8 of Form 33-506F4, or under this subsection, within 1 year of the change.

4.2 Application to Change or Surrender Individual Registration Categories - A registered individual of a registered firm who applies to change or surrender his or her registration category with the firm must make the application by submitting to the Director in accordance with Rule 31-509 a completed Form 33-506F2.

4.3 Termination of Relationship - A registered firm must, within 5 business days of a termination of an employment, partner, or agency relationship with a registered individual, notify the Director of the termination of the relationship by submitting in accordance with Rule 31-509 a completed Form 33-506F1.

PART 5 CHANGES TO NON-REGISTERED INDIVIDUAL INFORMATION

5.1 Changes to Form 33-506F4 Information

(1) Except as provided in subsections (2) and (3), a registered firm must notify the Director in accordance with Rule 31-509 of a change to any information previously submitted in Form 33-506F4, or under this subsection, for a non-registered individual within 5 business days of the change.

(2) Despite subsection (1), a registered firm must notify the Director in accordance with Rule 31-509 of a change to information previously submitted in Item 3 of Form 33-506F4, or under this subsection, for a non-registered individual within 1 year of the change.

(3) Despite subsection (1), a registered firm must notify the Director of a change to any information regarding a category of non-registered individual listed in Item 6 of Form 33-506F4 for a non-registered individual by submitting in accordance with Rule 31-509 a completed Form 33-506F2 within 5 business days of the change.

5.2 Termination of Relationship - A registered firm must, within 5 business days of an individual ceasing to be an non-registered individual of the registered firm, notify the Director in accordance with Rule 31-509 of the termination of the relationship by submitting a completed Form 33-506F1.

PART 6 DUE DILIGENCE AND RECORD-KEEPING

6.1 Sponsoring Firm Obligations

(1) A sponsoring firm must make reasonable efforts to ensure that information submitted by

(a) the firm for a non-registered individual; or

(b) a registered individual, or an individual applying for registration, for whom the firm is the sponsoring firm,

is true and complete.

(2) A sponsoring firm must retain all documents used by the firm to satisfy its obligation under subsection (1),

(a) in the case of a non-registered individual, for a period of 7 years after the individual ceases to be a non-registered individual; or

(b) in the case of a registered individual, or an individual applying for registration, for a period of 7 years after the individual ceases to be a registered individual with the firm.

(3) Without limiting the generality of subsection (2), if a registered individual, or an individual applying for registration, appoints an agent for service, the sponsoring firm must keep the original Appointment of Agent for Service executed by the individual for the period of time set out in paragraph (2)(b).

(4) A sponsoring firm that retains a document under subsection (2) or (3) in respect of an NRD submission must record the NRD submission number on the document.

PART 7 EXEMPTION

7.1 Exemption - The Director may grant an exemption from this Rule, in whole or in part, subject to such conditions or restrictions as may be imposed in the exemption.

PART 8 TRANSITION TO NRD

8.1 Definitions - In this Part

"data transfer date" means the day on which the Commission will commence the transfer of its record of non-registered individuals, registered individuals, and registered firms to NRD;

"NRD access date" means, for an NRD firm filer, the date the NRD firm filer first has access to NRD to make NRD submissions; and

"NRD freeze period" means the period that begins on the day that is 5 business days before the data transfer date and ends on the day that is 5 business days after the NRD access date.

8.2 Changes to Form 5 Information - A notice of change under section 3.1 is not required during the NRD freeze period if the change relates to

(a) the addition of an officer, partner, or director to the registered firm, and if a completed Form 33-506F4 in respect of the officer, partner, or director is submitted in accordance with Rule 31-509 within 30 business days of the NRD access date;

(b) the resignation or termination of an officer, partner or director of the registered firm, and if a completed Form 33-506F1 is submitted in accordance with Rule 31-509 within 30 business days of the NRD access date; or

(c) a business location other than head office, and if a completed Form 33-506F3 is submitted in accordance with Rule 31-509 within 30 business days of the NRD access date.

8.3 Changes to Business Location - A registered firm is exempt from the requirement to make a submission under section 3.2 during the NRD freeze period, if the firm makes the submission in accordance with Rule 31-509 within 30 business days of the NRD access date.

8.4 Addition of Non-registered Individuals - A registered firm is exempt from the requirement to make a submission under section 3.3 during the NRD freeze period, if the firm makes the submission in accordance with Rule 31-509 within 30 business days of the NRD access date.

8.5 Changes to Form 7 Information - Registered Individuals

(1) This section applies to a registered individual who has not submitted in accordance with Rule 31-509 a completed Form 33-506F4.

(2) A registered individual must notify the Director of a change to any information previously submitted in Form 7, or under this subsection, by submitting a completed Form 33-506F5 in paper format within 5 business days of the change.

(3) A registered individual who has submitted a completed Form 33-506F5 under subsection (2), must submit in accordance with section 8.7 of Rule 31-509 a completed Form 33-506F4 .

8.6 Termination of Relationship - Registered Individuals - A registered firm is exempt from the requirement to make a submission under section 4.3 during the NRD freeze period, if the firm makes the submission in accordance with Rule 31-509 within 30 business days of the NRD access date.

8.7 Changes to Form 7 Information - Non-registered Individuals

(1) This section applies to a registered firm that has not submitted in accordance with Rule 31-509 a completed Form 33-506F4 for a non-registered individual.

(2) A registered firm must notify the Director of a change to any information previously submitted in Form 7 for a non-registered individual, or under this subsection, by submitting a completed Form 33-506F5 in paper format within 5 business days of the change.

(3) A registered firm that has submitted a completed Form 33-506F5 for a non-registered individual under subsection (2), must submit in accordance with section 8.8 of Rule 31-509 a completed Form 33-506F4 for the non-registered individual.

8.8 Termination of Relationship - Non-registered Individuals - A registered firm is exempt from the requirement to make a submission under section 5.2 during the NRD freeze period, if the firm makes the submission in accordance with Rule 31-509 within 30 business days of the NRD access date.

PART 9 EFFECTIVE DATE

9.1 Effective Date - This Rule comes into force on November 20, 2002.

FORM 33-506F1

NOTICE OF TERMINATION

Enter the following information using the online version of this submission at the NRD web site (www.nrd.ca). However, if the NRD filer is relying on the temporary hardship exemption in Rule 31-509, this form is required to be delivered to the regulator in paper format.

1. Individual

Name of individual: _________________________________

NRD number of individual: _________________________________

2. Business location

Name of firm: _________________________________

Address of relevant business location: _________________________________

NRD number of relevant business location: _________________________________

3. Individual categories

Indicate the registration or non-registered category of the individual as of the last date of employment:

4. Termination

Effective date of termination:

Indicate whether the individual:

was dismissed for cause _____________________
was dismissed in good standing _____________________
resigned in good standing _____________________
is deceased. _____________________

Include details regarding any:

unresolved client complaints:
internal discipline matters:
restrictions for violation of regulatory requirements:
financial obligations the individual has to clients:

Notice of Collection and Use of Personal Information

The personal information required under this form is collected on behalf of and used by the securities regulatory authorities set out below for the administration and enforcement of certain provisions of the securities legislation in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, New Brunswick, Prince Edward Island, Newfoundland, Northwest Territories, Yukon Territory and Nunavut.

(In the final draft of the form a list of contact information will be included here.)

WARNING:

It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue.

CERTIFICATION

The following certification is to be used when submitting this form in NRD format:

[ ] I am making this submission as agent for the NRD filer. By checking this box I certify that all statements of fact in this submission were provided to me by the NRD filer and that this submission is being made at the request of the NRD filer.

OR

The following certification is to be used when submitting this form in paper format:

I, the undersigned, certify that I have read and that I understand the questions in the notice and the Warning set out above. I also certify that all statements of fact made in the answers to the questions are true.

Dated this _____________________ day of _____________________ , 20 ________ .

Name of firm: _________________________________

Authorized signature: _________________________________

Print name: _________________________________

Title: _________________________________

FORM 33-506F2

CHANGE OR SURRENDER OF INDIVIDUAL CATEGORIES

1. Individual

Name of individual: _________________________________

NRD number of individual: _________________________________

2. Individual categories

Indicate the individual categories that the individual is adding or removing:

3. Details of surrender

If the individual is surrendering his or her registration include details regarding any:

unresolved client complaints:
internal discipline matters:
restrictions for violation of regulatory requirements that occurred at any time during individual's employment with the firm:
financial obligations the individual has to clients:

Notice of Collection and Use of Personal Information

By submitting this information you consent to the collection by the securities regulatory authority of the personal information provided above, police records, records from other government or non-governmental regulatory authorities or self-regulatory organizations, credit records and employment records about you as may be necessary for the securities regulatory authority to complete its review of the information submitted above including your continued fitness for registration, if applicable, in accordance with the legal authority of the securities regulatory authority for the duration of the period which you remain registered or approved by the securities regulatory authority. The sources the securities regulatory authority may contact include government and private bodies or agencies, individuals, corporations and other organizations.

(In the final draft of the form a list of contact information will be included here.)

WARNING:

It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue.

CERTIFICATION:

The following certification is to be used when submitting this form in NRD format:

[ ] I am making this submission as agent for the NRD filer. By checking this box I certify that all statements of fact in this submission were provided to me by the NRD filer and that this submission is being made at the request of the NRD filer.

The following certification is to be used when submitting this form in paper format:

I, the undersigned, certify that I have read and that I understand the questions in this notice and the Warning set out above. I also certify that all statements of fact made in the answers to the questions are true.

_________________________________	________
Signature of registered or non-registered individual	Date

Name of firm: _________________________________

Authorized signature: _________________________________

Print name: _________________________________

Title: _________________________________

Date: ________

FORM 33-506F3

BUSINESS LOCATIONS OTHER THAN HEAD OFFICE

Please select one box:

[ ] This form is being submitted to notify the regulator of the opening of this business location. Complete the entire form.

[ ] This form is being submitted to notify the regulator of the closing of this business location. Complete the entire form.

[ ] This form is being submitted to notify the regulator the change of information previously submitted in respect of this business location. Complete the entire form and describe the information that has changed (for example, "telephone number" or "type of business location"):___________________________________

1. Type of business location

________ branch

________ sub-branch

2. Supervisor or branch manager

NRD number of the designated supervisor or branch manager: _________________________________

Name of designated supervisor or branch manager: _________________________________

3. Business location information

Business address: _________________________________

Telephone number: ( ) _____________________

Facsimile number: ( ) _____________________

Mailing address (if different from business address): _________________________________

Notice of Collection and Use of Personal Information

(In the final draft of the form a list of contact information will be included here.)

WARNING:

It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue.

CERTIFICATION

The following certification is to be used when submitting this form in NRD format:

[ ] I am making this submission as agent for the NRD filer. By checking this box I certify that all statements of fact in this submission were provided to me by the NRD filer and that this submission is being made at the request of the NRD filer.

The following certification is to be used when submitting this form in paper format:

I, the undersigned, certify that I have read and that I understand the questions in this notice and the Warning set out above. I also certify that all statements of fact made in the answers to the questions are true.

Name of firm: _________________________________

Authorized signature: _________________________________

Print name: _________________________________

Title: _________________________________

Date: _________________________________

FORM 33-506F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL

SUBMISSION TO NRD

INSTRUCTIONS FOR FILING IN PAPER FORMAT

1. This form is to be used by every individual seeking registration or approval from a securities regulatory authority or a self-regulatory organization.

2. This form is also to be used by any sole proprietor submitting an application for registration as a dealer, broker, adviser or underwriter to a securities regulatory authority.

3. Failure to answer all applicable questions may cause delays in the processing of the application form.

4. This form and all attachments added thereto must be legible.

5. All attachments pertaining to any question must be made exhibits to the form and each one must be so marked. All signatures must be originals.

6. To complete the application, individuals should seek advice from an authorized officer of the sponsoring firm or from a legal adviser.

7. The number of originally-signed copies of the form to be filed with the self-regulatory organization and/or securities regulatory authority or similar authority varies from province to province. If unsure of the procedure, please consult the Registration Department of the self-regulatory organization through which you are applying or the applicable securities regulatory authority, or similar authority.

Item 1 - Name

1. Legal name

_____________

_____________

_____________

_____________

Last name

First name

Second name

Third name

(if applicable)

(if applicable)

2. Other names

Are you currently, or have you previously been, known by a name other than the name

mentioned above? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "A".

Item 2 - Residential address

Current and previous addresses

Provide all residential addresses, including any foreign residential addresses, for the past 10 years.

Current residential address: _________________________________

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

Telephone number: ( ) ________

Resided at this address since: ________ (YYYY/MM)

If you have resided at this address for less than 10 years, complete Schedule "B".

Item 3 - Personal information

Personal description

Date of birth: _____________________

Place of birth: _____________________

(YYYY/MM/DD)

(city, province, territory or state, country)

Gender:

[ ] Female

Colour of eyes:

Colour of hair:

[ ] Male

Height: imperial units: ________

OR

metric units: ________

Weight: imperial units: ________

OR

metric units: ________

Item 4 - Citizenship

Citizenship information

What is your citizenship?

[ ] Canadian

[ ] Other, specify: _________________________________

If you are a citizen of a country other than Canada, complete the following for that other citizenship. You are only required to provide the following information for one citizenship.

Passport number: _____________________

Country of citizenship: _____________________

Date of issue: _____________________(YYYY/MM/DD)

Place of issuance: _________________________________

(city, province, territory or state, country)

Item 5 - Registration jurisdictions

Jurisdictions

Indicate, by checking the appropriate box, each province or territory to which you are applying:

[ ] Alberta

[ ] Northwest Territories

[ ] Prince Edward Island

[ ] British Columbia

[ ] Nova Scotia
ONTARIO SECURITIES COMMISSION RULE 33-506 (COMMODITY FUTURES ACT) REGISTRATION INFORMATION PART 1 DEFINITIONS 1.1 Definitions - In this Rule "non-registered individual" means, for a registered firm or for a person or company that is applying for registration, an individual who is not registered to trade or advise on behalf of the firm and who (a) is a director, partner, or officer of the firm, or (b) beneficially owns, directly or indirectly, or exercises control or direction over, 10 percent or more of the voting securities of the firm; "Rule 31-509" means Ontario Securities Commission Rule 31-509 (Commodity Futures Act) National Registration Database; "NRD submission number" means the unique number generated by NRD to identify each NRD submission; "registered firm" means a person or company that is registered as a dealer or adviser; "registered individual" means, for a registered firm, an individual who is registered to trade or advise on behalf of the registered firm; "sponsoring firm" means, (a) for a registered individual, the registered firm on whose behalf the individual trades or advises, (b) for an individual applying for registration, the registered firm, or the person or company applying to become a registered firm, on whose behalf the individual proposes to trade or advise, (c) for a non-registered individual of a registered firm, the registered firm, or (d) for a non-registered individual of a person or company that is applying for registration, the person or company that is applying for registration. 1.2 Interpretation - Terms defined in Rule 31-509 and used in this Rule have the respective meanings ascribed to those terms in Rule 31-509. PART 2 APPLICATION FOR REGISTRATION 2.1 Dealer and Adviser Registration - An applicant for registration as a dealer or adviser must submit to the Director (a) in paper format a completed Form 5; (b) in accordance with Rule 31-509, a completed Form 33-506F3 for each business location of th 1. Individual Name of individual: _____________________________________
NRD number of individual: _________________________________
2. Business location Name of firm: _________________________________
Address of relevant business location: _________________________________
NRD number of relevant business location: ______________________________ ___
3. Individual categories Indicate the registration or non-registered category of the individual as of the last date of employment: 4. Termination Effective date of termination: Indicate whether the individual: was dismissed for cause _____________________ - was dismissed in good standing _____________________ - resigned in good standing _____________________ - is deceased. ________________ - Include details regarding any: unresolved client complaints: - internal discipline matters: - restrictions for violation of regulatory requirements: - financial obligations the individual has to clients: - Notice of Collection and Use of Personal Information The personal information required under this form is collected on behalf of and used by the securities regulatory authorities set out below for the administration and enforcement of certain provisions of the securities legislation in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, New Brunswick, Prince Edward Island, Newfoundland, Northwest Territories, Yukon Territory and Nunavut. If you have any questions about the collection and use of this information, you may contact the securities regulatory authority in any jurisdiction in which the required information is filed, at the address or telephone number set out below. (In the final draft of the form a list of contact information will be included here.) WARNING: It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue. CERTIFICATION The following certification is to be used when submitting this form in NRD format: [ ] I am making this submission as agent for the NRD filer. By checking this box I certify that all statements of fact in this submission were provided to me by the NRD filer and that this submission is being made at the request of the NRD filer. OR The following certification is to be used when submitting this form in Authorized signature: _____________________________________
Print name: _____________________________________
Title: _________________________________
Date: ________ FORM 33-506F3 BUSINESS LOCATIONS OTHER THAN HEAD OFFICE Enter the following information using the online version of this submission at the NRD web site (www.nrd.ca). However, if the NRD filer is relying on the temporary hardship exemption in Rule 31-509, this form is required to be delivered to the regulator in paper format. Please select one box: [ ] This form is being submitted to notify the regulator of the opening of this business location. Complete the entire form. [ ] This form is being submitted to notify the regulator of the closing of this business location. Complete the entire form. [ ] This form is being submitted to notify the regulator the change of information previously submitted in respect of this business location. Complete the entire form and describe the information that has changed (for example, "telephone number" or "type of business location"): ___________________________________
1. Type of business location ________ branch ________ sub-branch 2. Supervisor or branch manager NRD number of the designated supervisor or branch manager: __________________________________
Name of designated supervisor or branch manager: __________________________________
3. Business location information Business address: ____________________________________
Telephone number: ( ) _____________________ Facsimile number: ( ) _____________________
Mailing address (if different from business address): ____________________________________
Notice of Collection and Use of Personal Information The personal information required under this form is collected on behalf of and used by the securities regulatory authorities set out below for the administration and enforcement of certain provisions of the securities legislation in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, New Brunswick, Prince Edward Island, Newfoundland, Northwest Territories, Yukon Territory and Nunavut. If you have any questions about the collection and use of this information, you may contact the securities regulatory authority in any jurisdiction in which the required information is filed, at the address or telephone number set out below. (In the final draft of the form a list of contact information will be included here.) WARNING: It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue. CERTIFICATION The following certification is to be used when submitting this form in NRD format: [ ] I am making this submission as agent for the NRD filer. By checking this box I certify that all statements of fact in this submission were provided to me by the NRD filer and that this submission is being made at the request of the NRD filer. OR The following certification is to be used when submitting this form in paper format: I, the undersigned, certify that I have read and that I understand the questions in this notice and the Warning set out above. I also certify that all statements of fact made in the answers to the questions are true. Name of firm: ________________________________
Authorized signature: ____________________________________
Print name: _____________________________________
Title: ________________________________
Date: ________________________________
FORM 33-506F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL SUBMISSION TO NRD Enter the following information using the online version of this submission at the NRD web site (www.nrd.ca). However, if the NRD filer is relying on the temporary hardship exemption in Rule 31-509, this form is required to be delivered to the regulator in paper format. INSTRUCTIONS FOR FILING IN PAPER FORMAT 1. This form is to be used by every individual seeking registration or approval from a securities regulatory authority or a self-regulatory organization. 2. This form is also to be used by any sole proprietor submitting an application for registration as a dealer, broker, adviser or underwriter to a securities regulatory authority. 3. Failure to answer all applicable questions may cause delays in the processing of the application form. 4. This form and all attachments added thereto must be legible. 5. All attachments pertaining to any question must be made exhibits to the form and each one must be so marked. All signatures must be originals. 6. To complete the application, individuals should seek advice from an authorized officer of the sponsoring firm or from a legal adviser. 7. The number of originally-signed copies of the form to be filed with the self-regulatory organization and/or securities regulatory authority or similar authority varies from province to province. If unsure of the procedure, please consult the Registration Department of the self-regulatory organization through which you are applying or the applicable securities regulatory authority, or similar authority. Item 1 - Name 1. Legal name - 2. Other names Are you currently, or have you previously been, known by a name other than the name mentioned above? ________________________
[ ] Yes [ ] No If "Yes", complete Schedule "A". Item 2 - Residential address Current and previous addresses - Item 3 - Personal information Personal description - Item 4 - Citizenship Citizenship information What is your citizenship? [ ] Canadian [ ] Other, specify: _____________________________
If you are a citizen of a country other than Canada, complete the following for that other citizenship. You are only required to provide the following information for one citizenship. - Item 5 - Registration jurisdictions Jurisdictions Indicate, by checking the appropriate box, each province or territory to which you are applying: - Item 6 - Individual categories Categories Indicate, by checking the appropriate box in Schedule "C", each category for which you are applying. Item 7 - Address and agent for service 1. Address for service You must have one address for service in each province or territory in which you are now, or are applying to become, a registered individual or non-registered individual. A post office box is not an acceptable address for service. Complete Schedule "D" for each additional address for service you are providing. - 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. - Item 8 - Proficiency 1. Course or examination information Complete Schedule "E" to indicate each course and examination that you have successfully completed or for which you have received an exemption. [ ] Check here if you are not required under securities legislation or the rules of a self-regulatory organization to satisfy any course or examination requirements. 2. Student numbers Provide your student numbers below: Canadian Securities Institute (CSI): _______________________________
Investment Funds Institute of Canada (IFIC): ________________________________
Institute of Canadian Bankers (ICB): _________________________________
Association for Investment Management and Research (AIMR): _____________________ Canadian Association of Insurance and Financial Advisors (CAIFA): _____________________ 3. Exemption refusal Has any securities regulatory authority or self-regulatory organization refused to grant you an exemption from a course, examination or experience requirement? __________________________________
[ ] Yes [ ] No If "Yes", complete Schedule "F". Item 9 - Location of employment Location of employment Provide the following information for the location of the sponsoring firm at which you are currently working or will be working. If you are working, or will be working, out of more than one location, provide the following information for the location out of which you will be doing most of your business. - Item 10 - Current employment Employment information On Schedule "G", provide the information requested about your current business and employment activities, including those with your sponsoring firm. [ ] Check here if you are not required under securities legislation to provide this information. Item 11 - Previous employment Employment information On Schedule "H", provide the information requested in respect of your previous business and employment activities for the 10-year period before the date of this application. Include any periods of self-employment or unemployment during this period. Do not include summer employment while you were a full-time student. In addition, provide the information requested in respect of all of your securities or exchange contracts (including commodity futures contracts and commodity futures options) business and employment activities during and prior to the ten-year period. [ ] Check here if you are not required under securities legislation to provide this information. [ ] Check here if the information required by this section has been provided in Item 10. Item 12 - Resignations and terminations Resignation and termination information Have you ever resigned or been terminated following allegations, made by a client, sponsoring firm, self-regulatory organization, securities regulatory authority or any other regulatory authority that you: a) violated investment related statutes, regulations, rules or industry standards of conduct? ________ [ ] Yes [ ] No b) failed to supervise in connection with investment related statutes [ ] Yes [ ] No c) committed fraud or the wrongful taking of property? _____________________ [ ] Yes [ ] No If you have answered "Yes" to any of the above questions provide, for each resignation or termination, (1) the name of the firm from which you resigned or were terminated, (2) whether you resigned or were terminated, (3) the date you resigned or were terminated, and (4) the circumstances relating to your resignation or termination (including whether the allegations were made by a client, sponsoring firm, self-regulatory organization or regulatory authority). Item 13 - Regulatory disclosure 1. Securities regulatory authorities a) Other than a registration that has been recorded on NRD under the NRD number you are using to make this submission, are you now, or have you ever been, registered or licensed to trade in or advise on securities or exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? _____________________ [ ] Yes [ ] No If "Yes", complete Schedule "I", section 1(a). b) Are you now, or have you ever been, a partner, director, officer, or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of any firm which has been registered or licensed, or is now registered or licensed, (except as an issuer if you are or were a shareholder) to trade in or advise on securities or exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? ________ [ ] Yes [ ] No If "Yes", complete Schedule "I", section 1(b). c) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that f [ ] Yes [ ] No If "Yes", complete Schedule "I", section 1(d). e) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been subject to a cease trade order, a cease distribution order, a suspension or termination order, any disciplinary proceedings or any order resulting from disciplinary proceedings pursuant to securities legislation or legislation governing exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? ________________________________
[ ] Yes [ ] No If "Yes", complete Schedule "I", section 1(e). 2. Self-regulatory organizations a) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been a member or participating organization of any stock exchange or other self-regulatory organization in any province, territory, state or country? ____________________________________
[ ] Yes [ ] No If "Yes", complete Schedule "I", section 2(a). b) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been refused membership or entry as a participating organization in any stock exchange or other self-regulatory organization in any province, territory, state or country? ___________________________________
[ ] Yes [ ] No If "Yes", complete Schedule "I", section 2(b). c) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been subject to a suspension, expulsion or termination order, or been subject to any disciplinary proceedings or any order resulting from disciplinary proceedings conducted by any stock exchange or other self-regulatory organization in any province, territory, state or country? _________________________________ [ ] Yes [ ] No If "Yes", complete Schedule "I", section 2(c). 3. Non-securities regulation a) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been registered or licensed under any legislation which requires registration or licensing to deal with the public in any capacity other than to trade in or advise on securities or exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? _________________________________ [ ] Yes [ ] No If "Yes", complete Schedule "I", section 3(a). b) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been refused registration or a license under any legislation which requ
[ ] Québec

[ ] Manitoba

[ ] Nunavut

[ ] Saskatchewan

[ ] New Brunswick

[ ] Ontario

[ ] Yukon Territory

[ ] Newfoundland

Item 6 - Individual categories

Categories

Indicate, by checking the appropriate box in Schedule "C", each category for which you are applying.

Item 7 - Address and agent for service

1. Address for service

You must have one address for service in each province or territory in which you are now, or are applying to become, a registered individual or non-registered individual. A post office box is not an acceptable address for service. Complete Schedule "D" for each additional address for service you are providing.

Address for service: _________________________________

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

Telephone number: ( ) _____________________

Fax number: ( ) _____________________

E-mail address: _________________________________

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

Item 8 - Proficiency

1. Course or examination information

Complete Schedule "E" to indicate each course and examination that you have successfully completed or for which you have received an exemption.

[ ] Check here if you are not required under securities legislation or the rules of a self-regulatory organization to satisfy any course or examination requirements.

2. Student numbers

Provide your student numbers below:

Canadian Securities Institute (CSI): _________________________________

Investment Funds Institute of Canada (IFIC): _________________________________

Institute of Canadian Bankers (ICB): _________________________________

Association for Investment Management and Research (AIMR): _____________________

Canadian Association of Insurance and Financial Advisors (CAIFA): _____________________

3. Exemption refusal

Has any securities regulatory authority or self-regulatory organization refused to grant you an exemption from a course, examination or experience requirement? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "F".

Item 9 - Location of employment

Location of employment

Provide the following information for the location of the sponsoring firm at which you are currently working or will be working. If you are working, or will be working, out of more than one location, provide the following information for the location out of which you will be doing most of your business.

NRD number: _____________________

Business address: _________________________________

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

Telephone number: ( ) ________

Fax number: ( ) ________

[ ] Check here if the mailing address of the location is the same as the business address provided above. Otherwise, complete the following:

Mailing address: _________________________________

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

Item 10 - Current employment

Employment information

On Schedule "G", provide the information requested about your current business and employment activities, including those with your sponsoring firm.

[ ] Check here if you are not required under securities legislation to provide this information.

Item 11 - Previous employment

Employment information

On Schedule "H", provide the information requested in respect of your previous business and employment activities for the 10-year period before the date of this application. Include any periods of self-employment or unemployment during this period. Do not include summer employment while you were a full-time student.

In addition, provide the information requested in respect of all of your securities or exchange contracts (including commodity futures contracts and commodity futures options) business and employment activities during and prior to the ten-year period.

[ ] Check here if you are not required under securities legislation to provide this information.

[ ] Check here if the information required by this section has been provided in Item 10.

Item 12 - Resignations and terminations

Resignation and termination information

Have you ever resigned or been terminated following allegations, made by a client, sponsoring firm, self-regulatory organization, securities regulatory authority or any other regulatory authority that you:

a) violated investment related statutes, regulations, rules or industry standards of conduct? ________ [ ] Yes [ ] No

b) failed to supervise in connection with investment related statutes, regulations, rules or industry standards of conduct? _________________________________ [ ] Yes [ ] No

c) committed fraud or the wrongful taking of property? _____________________ [ ] Yes [ ] No

If you have answered "Yes" to any of the above questions provide, for each resignation or termination, (1) the name of the firm from which you resigned or were terminated, (2) whether you resigned or were terminated, (3) the date you resigned or were terminated, and (4) the circumstances relating to your resignation or termination (including whether the allegations were made by a client, sponsoring firm, self-regulatory organization or regulatory authority).

Item 13 - Regulatory disclosure

1. Securities regulatory authorities

a) Other than a registration that has been recorded on NRD under the NRD number you are using to make this submission, are you now, or have you ever been, registered or licensed to trade in or advise on securities or exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? _____________________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 1(a).

b) Are you now, or have you ever been, a partner, director, officer, or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of any firm which has been registered or licensed, or is now registered or licensed, (except as an issuer if you are or were a shareholder) to trade in or advise on securities or exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? ________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 1(b).

c) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been refused registration or a license to trade in or advise on securities or exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? _____________________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 1(c).

d) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been denied the benefit of any exemption from registration provided by securities legislation or legislation governing exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 1(d).

e) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been subject to a cease trade order, a cease distribution order, a suspension or termination order, any disciplinary proceedings or any order resulting from disciplinary proceedings pursuant to securities legislation or legislation governing exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 1(e).

2. Self-regulatory organizations

a) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been a member or participating organization of any stock exchange or other self-regulatory organization in any province, territory, state or country? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 2(a).

b) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been refused membership or entry as a participating organization in any stock exchange or other self-regulatory organization in any province, territory, state or country? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 2(b).

c) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been subject to a suspension, expulsion or termination order, or been subject to any disciplinary proceedings or any order resulting from disciplinary proceedings conducted by any stock exchange or other self-regulatory organization in any province, territory, state or country? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 2(c).

3. Non-securities regulation

a) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been registered or licensed under any legislation which requires registration or licensing to deal with the public in any capacity other than to trade in or advise on securities or exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 3(a).

b) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been refused registration or a license under any legislation which requires registration or licensing to deal with the public in any capacity other than to trade in or advise on securities or exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 3(b).

c) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been subject to a suspension or termination order, or disciplinary proceedings or any order resulting from disciplinary proceedings conducted under any legislation which requires registration or licensing to deal with the public in any capacity other than to trade in or advise on securities or exchange contracts (including commodity futures contracts and commodity futures options) in any province, territory, state or country? ________ [ ] Yes [ ] No

If "Yes", complete Schedule "I", section 3(c).

Item 14 - Criminal disclosure

Criminal, provincial and territorial offences

With respect to questions (b) and (d) below, if you or your firm have pleaded guilty or been found guilty of an offence, such offence must be reported even if an absolute or conditional discharge has been granted with respect to the offence. You are not required to disclose any offence for which a pardon has been granted under the Criminal Records Act (Canada) unless the pardon has been revoked. You are not required to disclose speeding or parking violations.

a) Is there currently an outstanding charge against you alleging an offence that was committed in any province, territory, state, or country? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "J", section (a).

b) Have you, since attaining the age of 18, ever been convicted of, pleaded guilty to or no contest to an offence that was committed in any province, territory, state, or country? _____________________ [ ] Yes [ ] No

If "Yes", complete Schedule "J", section (b).

c) Have charges been laid, alleging an offence that was committed in any province, territory, state, or country against any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)) in which you are or were at the time of such event a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities? _____________________ [ ] Yes [ ] No

If "Yes", complete Schedule "J", section (c).

d) Has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been convicted of, pleaded guilty to or no contest to an offence that was committed in any province, territory, state, or country? _____________________ [ ] Yes [ ] No

If "Yes", complete Schedule "J", section (d).

Item 15 - Civil disclosure

Current and past civil proceedings

a) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been a defendant or respondent in any civil proceeding in any jurisdiction in which fraud, theft, deceit, misrepresentation, or similar conduct is, or was, alleged? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "K", section (a).

b) Other than what you disclosed in Item 15(a), were you, at the time the events that led to the civil proceeding occurred, a partner, director or officer or a holder of securities carrying more than 10 percent of the votes of all outstanding voting securities of a firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)) that is or was a defendant or respondent in any civil proceeding in any jurisdiction in which fraud, theft, deceit, misrepresentation, or similar conduct is or was alleged? ________ [ ] Yes [ ] No

If "Yes", complete Schedule "K", section (b).

Item 16 - Financial disclosure

1. Bankruptcy

Under the law of any province, territory, state, or country have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm:

a) had a petition in bankruptcy issued against you or the firm or made a voluntary assignment in bankruptcy? _________________________________ [ ] Yes [ ] No

b) made a proposal under any legislation relating to bankruptcy or insolvency? ________ [ ] Yes [ ] No

c) been subject to proceedings under any legislation relating to the winding up, dissolution or companies' creditors arrangement? _____________________ [ ] Yes [ ] No

d) been subject to or instituted any proceedings, arrangement or compromise with creditors (including having a receiver, receiver-manager, administrator or trustee appointed by or at the request of creditors, either privately, or through court process, or by order of a regulator, to hold your assets)? _________________________________ [ ] Yes [ ] No

If "Yes" to any of the above questions, complete Schedule "L", section 1.

2. Debt Obligations

Have you ever failed to meet a financial obligation of $500 or more as it came due, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been unable to meet its financial obligations as they came due? _________________________________ [ ] Yes [ ] No

If "Yes", complete Schedule "L", section 2.

3. Surety bond or fidelity bond

Have you ever applied for a surety or fidelity bond and been refused? _____________________ [ ] Yes [ ] No

If "Yes", complete Schedule "L", section 3.

4. Garnishments, unsatisfied judgments or directions to pay

Are there currently, or have there been, outstanding against you any of the following:

a) garnishments,

b) unsatisfied judgments, or

c) directions to pay issued by a federal, provincial, territorial or state authority? ________ [ ] Yes [ ] No

If "Yes", complete Schedule "L", section 4.

Item 17 - Related securities firms

Related securities firms and holdings

a) Other than with your sponsoring firm, are you a partner, director, or officer of a firm having as its principal business that of trading in or advising on securities or exchange contracts (including commodity futures contracts and commodity futures options)? _____________________ [ ] Yes [ ] No

If "Yes", complete Schedule "M".

b) Are you a holder of 10 percent or more of the voting securities of any firm (including your sponsoring firm) having as its principal business that of trading in or advising on securities or exchange contracts (including commodity futures contracts and commodity futures options)? ________ [ ] Yes [ ] No

If "Yes", complete Schedule "M".

Agent for service

By submitting this form you certify that in each jurisdiction in which you have appointed an agent for service you have properly executed the appointment of agent for service required by the regulator or the securities legislation of that jurisdiction.

Submission to jurisdiction

By submitting this application you irrevocably and unconditionally submit to the non-exclusive jurisdiction of the judicial, quasi-judicial and administrative tribunals of each jurisdiction to which you have submitted this application and any administrative proceeding in that jurisdiction, in any action, investigation or administrative, criminal, quasi-criminal, penal or other proceeding (each, a "Proceeding") arising out of or relating to or concerning your activities as a registrant or an officer, partner or director of a registrant under the securities legislation of the jurisdiction, and irrevocably waive any right to raise as a defence in any Proceeding any alleged lack of jurisdiction to bring that Proceeding.

Notice of collection and use of personal information

The personal information required under this form is collected on behalf of and used by the securities regulatory authorities set out below for purposes of the administration and enforcement of certain provisions of the securities legislation in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Québec, Nova Scotia, New Brunswick, Prince Edward Island, Newfoundland, Northwest Territories, Yukon Territory and Nunavut.

By submitting this application you consent to the collection by the securities regulatory authority to which this application is being submitted of the personal information contained in the application, police records, records from other government or non-governmental regulatory authorities or self-regulatory organizations, credit records and employment records about you as may be necessary for the securities regulatory authority to complete its review of your application or continued fitness for registration in accordance with the legal authority of the securities regulatory authority for the duration of the period which you remain registered or approved by the securities regulatory authority. The sources the securities regulatory authority may contact include government and private bodies or agencies, individuals, corporations and other organizations.

The principal purpose for which this collection of personal information is to be used is to assess your suitability for registration and to assess your continued fitness for registration in accordance with the applicable securities legislation.

If you have any questions about the collection and use of this information, you may contact the securities regulatory authority in any jurisdiction in which the required information is filed, at the address or telephone number set out below. In Québec, questions may also be addressed to the Commission d'accès à l'information du Québec (1-888-528-7741, web site: www.cai.gouv.qc.ca).

(In the final draft of the form a list of contact information will be included here.)

Self-Regulatory Organizations

The principal purpose for the collection of personal information is to assess your suitability for registration or approval and to assess your continued fitness for registration or approval in accordance with the applicable securities legislation and the by-laws, regulations, rules, rulings and policies (hereinafter collectively referred to as "rules") of the self-regulatory organizations.

By submitting this application, you certify that you are conversant with the rules of the applicable self-regulatory organizations of which you are seeking registration or approval or of which your sponsoring firm is a member or participating organization. You also undertake to become conversant with the rules of any self-regulatory organizations of which you or your sponsoring firm becomes a member or participating organization. You agree to be bound by, observe and comply with these rules as they are from time to time amended or supplemented, and you agree to keep yourself fully informed about them as they are amended and supplemented. You submit to the jurisdiction of the self-regulatory organizations to which you are applying for registration or approval, or of which your sponsoring firm is now or in the future becomes a member or participating organization and, wherever applicable, their Governors, Directors and Committees. You agree that any registration or approval granted pursuant to this application may be revoked, terminated or suspended at any time in accordance with the then applicable rules of the respective self-regulatory organizations. In the event of any such revocation or termination, you must terminate all activities which require registration or approval and, thereafter, not perform services that require registration or approval for any member of the self-regulatory organizations or any approved affiliated company or other affiliate of such member without obtaining the approval of or registration with the self-regulatory organizations, in accordance with their rules.

By submitting this application, you undertake to notify the self-regulatory organizations to which you are applying for registration or approval or with which you are currently or may in the future be registered or approved of any material change to the information herein provided in accordance with their respective rules. You agree to the transfer of this application form, without amendment, to other self-regulatory organizations in the event that at some time in the future you apply to such other self-regulatory organizations for registration or approval.

You certify that you have discussed the questions in this application, together with this Agreement, with an Officer or Branch Manager of your sponsoring member firm and, to your knowledge and belief, the authorized Officer or Branch Manager was satisfied that you fully understood the questions and the terms of this Agreement. You further certify that your business activities will be limited strictly to those permitted by the category of your registration or approval.

WARNING: It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue.

CERTIFICATION:

The following certification is to be used when submitting this form in NRD format:

[ ] I am making this submission as agent for the NRD filer. By checking this box I certify that all statements of fact in this submission were provided to me by the NRD filer and that this submission is being made at the request of the NRD filer.

The following certification is to be used when submitting this form in paper format:

Certification by Individual

I, the undersigned, certify that I have read and that I understand this application form and the Warning set out above. I also certify that all statements of fact provided in this application are true.

_________________________________	_____________
Signature of applicant or non-registered individual	Date

Certification of Firm

I, the undersigned, certify on behalf of the sponsoring firm that the applicant will be engaged by the sponsoring firm as registered or approved. I certify that I have discussed the questions set out in this application with the applicant or where the applicant has applied through one of our branch offices the branch manager or another officer or partner has so done and I am satisfied that the applicant fully understands the questions.

_________________________________	_____________
Signature of authorized officer or partner	Date

SCHEDULE "A"Name

Item [ ] 1

Other names

_____________

_____________

_____________

_____________

Last name

First name

Second name

Third name

(if applicable)

(if applicable)

Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name).

When did you use this name?

From: _____________________

To: _____________________

(YYYY/MM)

(YYYY/MM)

_____________

_____________

_____________

_____________

Last name

First name

Second name

Third name

(if applicable)

(if applicable)

Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name).

When did you use this name?

From: _____________________

To: _____________________

(YYYY/MM)

(YYYY/MM)

_____________

_____________

_____________

_____________

Last name

First name

Second name

Third name

(if applicable)

(if applicable)

Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name).

When did you use this name?

From: _____________________

To: _____________________

(YYYY/MM)

(YYYY/MM)

SCHEDULE "B"Residential address

Item [ ] 2

Previous addresses

A postal code (or ZIP code) and a telephone number are not required for any previous address.

Residential address: _________________________________

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

When did you live at this address?

From: _____________________

To: _____________________

(YYYY/MM)

(YYYY/MM)

Residential address: _________________________________

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

When did you live at this address?

From: _____________________

To: _____________________

(YYYY/MM)

(YYYY/MM)

Residential address: _________________________________

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

When did you live at this address?

From: _____________________

To: _____________________

(YYYY/MM)

(YYYY/MM)

Residential address: ______________________________________

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

When did you live at this address?

From: _____________

To: _____________

(YYYY/MM)

(YYYY/MM)

Residential address: _________________________________

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

When did you live at this address?

From: _____________________

To: _____________________

(YYYY/MM)

(YYYY/MM)

SCHEDULE "C"Individual categories

Item [ ] 6

Categories

Indicate, by checking the appropriate box, each category for which you are applying.

(In the final draft of the form a list of the registration categories of each jurisdiction will be included here.)

SCHEDULE "D"Address and Agent for Service

Item [ ] 7

Address for Service

1. Address for service

You must have one address for service in each province or territory in which you are now, or are applying to become, a registered individual or non-registered 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: ( ) ________

E-mail address: _____________________

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)

Name of agent for service: _________________________________

Last name

First name

SCHEDULE "E"Proficiency

Item [ ] 8

Course or examination information

Indicate each course and examination that you have successfully completed or for which you have received an exemption.

(In the final draft of the form a list of courses and examinations will be included here. Further, spaces will be provided to set out dates of completion or exemption and the names of the exempting institutions)

SCHEDULE "F"Proficiency

Item [ ] 8

Exemption refusal

Complete the following for each exemption that was refused.

Which securities regulatory authority or self-regulatory organization refused to grant the exemption?

State the name of the course, examination or experience requirement:

State the reason given for not being granted the exemption:

Which securities regulatory authority or self-regulatory organization refused to grant the exemption?

State the name of the course, examination or experience requirement:

State the reason given for not being granted the exemption:

SCHEDULE "G"Current employment

Item [ ] 10

Employment information

Provide the information requested in respect of each of your current business and employment activities, including those with your sponsoring firm.

[ ] Unemployed

[ ] Full-time student

[ ] Employed or self-employed

From:

________

(YYYY/MM/DD)

You are only required to fill in the following if you have indicated above that you are employed or self-employed.

Name of business or employer:

_________________________________

Address of business or employer:

_________________________________

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

Name and title of immediate supervisor: _____________________

Describe the type of business or employment and your duties. If you are seeking a type of registration for which specified experience is required, provide details of that experience below (for example, level of responsibility, value of accounts under direct supervision, and research experience):

Indicate the number of hours per week you will be devoting to this business or employment: ________

Indicate the NRD number of the branch where you will be conducting the majority of your business or employment: ________

If the business or employment described above is with the sponsoring firm and if you are working less than 30 hours per week for the firm, explain why you are working less than 30 hours per week for the firm:

If the business or employment described above is not with the sponsoring firm, disclose any potential for confusion by clients and any potential for conflicts of interest arising from your proposed activities as a registrant and the business or employment described above (include whether the business is listed on an exchange):

SCHEDULE "H"Previous employment

Item [ ] 11

Employment information

Provide the information requested in respect of your previous business and employment activities for the 10-year period before the date of this application. Include any periods of self-employment or unemployment during this period. Do not include summer employment while you were a full-time student.

In addition, provide the information requested in respect of all of your securities or exchange contracts (including commodity futures contracts and commodity futures options) business and employment activities during and prior to the ten-year period.

[ ] Unemployed

[ ] Full-time student

[ ] Employed or self-employed

From: ________ (YYYY/MM/DD)

To: ________ (YYYY/MM/DD)

You are only required to fill in the following if you have indicated above that you are, or were, employed or self-employed.

Name of business or employer:

_________________________________

Address of business or employer:
_________________________________
(number, street, city, province, territory or state, country)

Name and title of immediate supervisor: _________________________________

Describe the type of business or employment and your duties. If you are seeking a type of registration for which specified experience is required, provide details of that experience below (for example, level of responsibility, value of accounts under direct supervision, and research experience):

SCHEDULE "I"Regulatory disclosure

Item [ ] 13

1. Securities regulatory authorities

a) For each registration or licence, indicate below (1) the securities regulatory authority with which you are, or were, registered or licensed, (2) the type or category of registration or licence, and (3) the dates between which you held the registration or licence.

b) For each registration or licence, indicate below (1) the name of the firm, (2) the securities regulatory authority with which the firm is, or was, registered or licensed, (3) the type or category of registration or licence, and (4) the dates between which you held the registration or licence.

c) For each registration or licence refused, indicate below (1) the party that was refused the registration or licence, (2) the securities regulatory authority that refused the registration or licence, (3) the type or category of registration or licence refused, (4) the date of the refusal, and (5) the reasons for the refusal.

d) For each exemption from registration denied, indicate below (1) the party that was denied the exemption, (2) the securities regulatory authority that denied the exemption, (3) the date the exemption was denied, and (4) any other information that you think is relevant or that is requested by the regulator.

e) For each order or disciplinary proceeding, indicate below (1) the party against whom the order was made or the proceeding taken, (2) the securities regulatory authority that issued the order or that is, or was, conducting the proceeding, (3) the date any notice of proceeding was issued, (4) the date any order or settlement was made, (5) a summary of any notice, order or settlement (including any sanctions imposed), and (6) any other information that you think is relevant or that is requested by the regulator.

2. Self-regulatory organizations

a) For each membership or participation, indicate below (1) the party that is, or was, a member or participating organization, (2) the self-regulatory organization with which the party is, or was, a member or participating organization, (3) the type or category of membership or participation, and (4) the dates between which the party was a member or participating organization.

b) For each membership or participation refused, indicate below (1) the party that was refused membership or participation, (2) the self-regulatory organization that refused the membership or participation, (3) the type or category of membership or participation refused, (4) the date of the refusal, and (5) the reasons for the refusal.

c) For each order or disciplinary proceeding, indicate below (1) the party against whom the order was made or the proceeding taken, (2) the self-regulatory organization that issued the order or that is, or was, conducting the proceeding, (3) the date any notice of proceeding was issued, (4) the date any order or settlement was made, (5) a summary of any notice, order or settlement (including any sanctions imposed), and (6) any other information that you think is relevant or that is requested by the regulator.

3. Non-securities regulation

a) For each registration or licence, indicate below (1) the party is, or was, registered or licensed, (2) with which regulatory authority, or under what legislation, the party is, or was, registered or licensed, (3) the type or category of registration or licence, and (4) the dates between which the party held the registration or licence.

b) For each registration or licence refused, indicate below (1) the party that was refused registration or licensing, (2) with which regulatory authority, or under what legislation, the registration or licence was refused, (3) the type or category of registration or licence refused, (4) the date of the refusal, and (5) the reasons for the refusal.

c) For each order or disciplinary proceeding, indicate below (1) the party against whom the order was made or the proceeding taken, (2) the regulatory authority that made the order or that is, or was, conducting the proceeding, or under what legislation the order was made or the proceeding is being, or was, conducted, (3) the date any notice of proceeding was issued, (4) the date any order or settlement was made, (5) a summary of any notice, order or settlement (including any sanctions imposed), and (6) any other information that you think is relevant or that is requested by the regulator.

SCHEDULE "J"Criminal disclosure

Item [ ] 14

Criminal, provincial and territorial offences

a) For each charge, indicate below (1) the charge, (2) the date of the charge, (3) any trial or appeal dates, and (4) the court location.

b) For each conviction, indicate below (1) the offence, (2) the date of the conviction, and (3) the disposition (state any penalty or fine and the date any fine was paid).

c) For each charge, indicate below (1) the name of the firm, (2) the charge, (3) the date of the charge, (4) any trial or appeal dates, and (5) the court location.

d) For each conviction, indicate below (1) the name of the firm, (2) the offence, (3) the date of the conviction, and (4) the disposition (state any penalty or fine and the date any fine was paid).

SCHEDULE "K"Civil disclosure

Item [ ] 15

Current and past civil proceedings

a) For each civil proceeding, indicate below (1) the party that is, or was, a defendant or respondent, (2) each plaintiff in the proceeding, (2) whether the proceeding is pending, on appeal or final, (3) the jurisdiction in which the action is being, or was, pursued, and (4) a summary of any disposition or settlement. (Disclosure must include those actions settled without admission of liability.)

b) For each civil proceeding, indicate below (1) the firm that was a defendant or respondent in the proceeding, (2) your relationship to the firm, (3) each plaintiff in the proceeding, (4) whether the proceeding is pending, on appeal or final, (5) the jurisdiction in which the action is being, or was, pursued, and (6) a summary of any disposition or settlement. (Disclosure must include those actions settled without admission of liability.)

SCHEDULE "L"Financial Disclosure

Item [ ] 16

1. Bankruptcy

For each event, indicate below (1) the party about whom this disclosure is being made, (2) any amounts currently owing, (3) the creditors, (4) the status of the matter, (5) a summary of any disposition or settlement, and (6) any other information that you think is relevant or that is requested by the regulator.

2. Solvency

For each event, indicate below (1) the party that is, or was, unable to meet its financial obligations, (2) the amount that was owing at the time the party could not meet its financial obligations, (3) the party to whom the amount is, or was, owing, (4) any relevant dates (for example, when payments are due or when final payment was made), (5) any amounts currently owing, and (6) any other information that you think is relevant or that is requested by the regulator.

3. Surety Bond or Fidelity Bond

For each bond refused, indicate below (1) the name of the bonding company, (2) the address of the bonding company, (3) the date of the refusal, and (4) the reasons for the refusal.

4. Garnishments, Unsatisfied Judgments or Directions to Pay

For each garnishment, unsatisfied judgement or direction to pay, indicate below (1) the amount that was owing at the time the garnishment, judgement or direction to pay was rendered, (2) the party to whom the amount is, or was, owing, (3) any relevant dates (for example, when payments are due or when final payment was made), (4) any amounts currently owing, and (5) any other information that you think is relevant or that is requested by the regulator.

SCHEDULE "M"Related securities firms

Item [ ] 17

Section 1 - Related Securities Firms and Holdings

Indicate below (a) the name of the firm and (b) your relationship to the firm.

a) Firm name: _________________________________

b) Relationship to the firm and period of relationship:

[ ]

Partner

From: ________/________

To: ________/________

(if applicable)

(YYYY/MM)

(YYYY/MM)

[ ]

Director

From: ________/________

To: ________/________

(if applicable)

(YYYY/MM)

(YYYY/MM)

[ ]

Officer

From: ________/________

To: ________/________

(if applicable)

(YYYY/MM)

(YYYY/MM)

[ ]

Holder of voting securities over 10 percent

From: ________/________

To: ________/________

(if applicable)

(YYYY/MM)

(YYYY/MM)

If you are a holder of 10 percent or more of the voting securities of the firm, complete (c), (d), (e), (f), and (g).

c) State the number, value, class and percentage of securities or the amount of partnership interest you own or propose to acquire upon approval. If acquiring shares upon approval, state source (for example, treasury shares, or if upon transfer, state name of transferor).

d) State the value of 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 (if applicable):

e) If another party has provided you with funds to invest in the firm, identify the party and state the relationship between you and that party:

f) Are the funds to be invested (or proposed to be invested) guaranteed directly or indirectly by any person or firm? _________________________________ [ ] Yes [ ] No

If "Yes", identify the party and state the relationship between you and that party:

g) Have you either directly or indirectly given up any rights with respect to such securities or partnership interest, or do you, on approval of this application, intend to give up any such rights (including by hypothecation, pledging or depositing as collateral the securities or partnership interest with any institution or person)? ________ [ ] Yes [ ] No

If "Yes", identify the party, state the relationship between you and that party and describe the rights that have been or will be given up:

h) Is a person other than you the beneficial owner of the shares, bonds, debentures, partnership units or other notes held by you? _____________________________________ [ ] Yes [ ] No

If "Yes", complete (i), (j) and (k).

i) Name of beneficial owner:

_____________

_____________

_____________

_____________

Last name

First name

Second name

Third name

(if applicable)

(if applicable)

j) Residential address:
_________________________________(number, street, city, province, territory or state, country, postal code)
k) Occupation:

FORM 33-506F5

CHANGE OF REGISTRATION INFORMATION

GENERAL INSTRUCTIONS

1. This notice must be submitted when notifying a regulator of changes to Form 3 or Form 4 information in accordance with Rule 33-506.

2. If the NRD filer is relying on the temporary hardship exemption in Rule 31-509, this form is required to be delivered to the regulator in paper format when notifying a regulator of changes to Form 33-506F4.

3. If this form is being submitting in respect of a change to a Form 3, Form 4 or Form 33-506F4 an authorized partner or officer of the firm must sign the form.

1. Type of form

Identify the part of the Form 3, Form 4, or Form 33-506F4 for which this notice is being provided. If this notice is being provided to update an individual's Form 4 or Form 33-506F4, provide the name of the individual.

[ ] Form 3, Item(s) ________ ,

[ ] Form 4, Item(s) ________ , name of individual ________ , or

[ ] Form 33-506F4, Item(s) ________ , name of individual

2. Details of Change

Provide the details of the change for each item identified above:

Notice of Collection and Use of Personal Information

By submitting this information you consent to the collection by the securities regulatory authority of the personal information provided above, police records, records from other government or non-governmental regulatory authorities or self-regulatory organizations, credit records and employment records about you as may be necessary for the securities regulatory authority to complete its review of your continued fitness for registration, if applicable, in accordance with the legal authority of the securities regulatory authority for the duration of the period which you remain registered or approved by the securities regulatory authority. The sources the securities regulatory authority may contact include government and private bodies or agencies, individuals, corporations and other organizations.

(In the final draft of the form a list of contact information will be included here.)

WARNING: It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue.

CERTIFICATION

I, the undersigned, certify that I have read and that I understand the questions in this notice and the Warning set out above. I also certify that all statements of fact made in the answers to the questions are true.

_________________________________	________
Signature of registered or non-registered individual	Date

(No signature is required here if this form is being submitted in respect of a change to Form 3 information.)

If this form is being submitted in respect of a change to Form 3, I, the undersigned, certify that I understand the requirements and the Warning in this notice and that all statements of fact provided in this notice are true.

Name of firm: _________________________________

Authorized signature: _________________________________

Print name: _________________________________

Title: _________________________________

Date: ________

COMPANION POLICY 33-506CP
TO ONTARIO SECURITIES COMMISSION RULE 33-506
(COMMODITY FUTURES ACT)

REGISTRATION INFORMATION

PART 1 BUSINESS LOCATIONS

1.1 Business Locations - The Commission is of the view that a business location for a registered firm, or a person or company that is applying for registration, is a location, including a residence, where a firm's registered individuals are based for the purpose of carrying out registerable activity.

PART 2 NOTICE OF CHANGES

2.1 Bulk Transfer of Locations and Individuals

(1) If a registered firm is acquiring a large number of business locations from one or more other registered firms (for example, as a result of an amalgamation or asset purchase) with a significant number of registered and non-registered individuals working out of each location, the Director will consider exempting the firms and individuals involved in the transaction from the following requirements, as necessary:

1. the requirement to submit a notice regarding the termination of each employment, partner, or agency relationship under section 4.3 of Rule 33-506;

2. the requirement to submit a notice regarding each individual who ceases to be a non-registered individual under section 5.2 of Rule 33-506;

3. the requirement to submit a registration application for each individual applying to become a registered individual under section 2.2 of Rule 33-506;

4. the requirement to submit a Form 33-506F4 for each non-registered individual under section 3.3 of Rule 33-506;

5. the requirement under section 3.1 of Rule 33-506 to notify the regulator of a change to the business location information in Form 33-506F3.

(2) In order to exempt the firms and individuals involved in the transaction from the requirements set out above, the application should include the following information:

(a) the name and NRD number of the registered firm that will acquire control of the business locations;

(b) for each registered firm that is transferring control of the business locations,

(i) the name and NRD number of the registered firm;

(ii) the address and NRD number of each business location that is being transferred from the registered firm named in (b)(i) to the registered firm named in (a); and

(c) the date that the business locations will be transferred to the registered firm named in (a).

(3) To facilitate the processing of the exemption application, the applicant may put the information referred to in subsection (2) in the form set out in Appendix A to this Companion Policy.

(4) This exemption application should be made by the registered firm that will acquire control of the business locations at the closing of the transaction and should be submitted sufficiently in advance of the date on which the business locations are to be transferred (the "transfer date"). At this time, the Commission is of the view that submitting the application at least 30 days prior to the transfer date should be sufficient.

(5) In addition to any application fee, it is likely that the payment of a fee will be a condition of this type of exemption order and that the fee will be related to the number of registered firms, business locations, registered individuals, and non-registered individuals involved in the transaction.

(6) As soon as practicable after the transfer date, the Director will instruct the NRD administrator to indicate the transfer of the business locations, the registered individuals, and the non-registered individuals on NRD.

PART 3 DUE DILIGENCE

3.1 Sponsoring Firm Obligations - The Commission is of the view that the reasonable efforts firms are required to undertake in Part 6 of MI 33-506 include

(a) establishing written policies and procedures relating to the investigation of an individual prior to submitting a Form 33-506F4 on behalf of the individual, and

(b) ensuring that the review of an individual pursuant to these policies and procedures is documented.

Appendix A

Request for NRD Bulk Transfer of Business Locations

This is an application for exemption under Rule 33-506 (Commodity Futures Act).

A)	Registered firm that will acquire the business locations
	Name:
	Firm NRD number:

B)	Registered firm transferring the business locations
	Name:
	Firm NRD number:

	Business locations that will be transferred
	Address of business location:
	NRD number of business location:

	Address of business location:
	NRD number of business location:
	(Repeat for each business location as necessary.)

C)	Date that business locations will be transferred:

Provide all residential addresses, including any foreign residential addresses, for the past 10 years.
Current residential address: _________________________________
(number, street, city, province, territory or state, country, postal code)
Telephone number: ( ) ________	Resided at this address since: ________ (YYYY/MM)
If you have resided at this address for less than 10 years, complete Schedule "B".

Date of birth: _____________________		Place of birth: _____________________
	(YYYY/MM/DD)	(city, province, territory or state, country)
Gender:	[ ] Female	Colour of eyes:		Colour of hair:
	[ ] Male
Height: imperial units: ________		OR	metric units: ________
Weight: imperial units: ________		OR	metric units: ________

Passport number: _____________________	Country of citizenship: _____________________
Date of issue: _____________________(YYYY/MM/DD)
Place of issuance: _________________________________
	(city, province, territory or state, country)

Address for service: _________________________________
(number, street, city, province or territory, postal code)
Telephone number: ( ) _____________________	Fax number: ( ) _____________________
E-mail address: _________________________________

Name of agent for service: _________________________________
(if applicable)
Contact person: _________________________________
	Last name	First name

NRD number: _____________________
Business address: _________________________________
(number, street, city, province, territory or state, country, postal code)
Telephone number: ( ) ________	Fax number: ( ) ________
[ ] Check here if the mailing address of the location is the same as the business address provided above. Otherwise, complete the following:
Mailing address: _________________________________
(number, street, city, province, territory or state, country, postal code)


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


Residential address: _________________________________
(number, street, city, province, territory or state, country)

When did you live at this address?	From: _____________________	To: _____________________
	(YYYY/MM)	(YYYY/MM)

[ ]	Partner	From: ________/________	To: ________/________	(if applicable)
		(YYYY/MM)	(YYYY/MM)
[ ]	Director	From: ________/________	To: ________/________	(if applicable)
		(YYYY/MM)	(YYYY/MM)
[ ]	Officer	From: ________/________	To: ________/________	(if applicable)
		(YYYY/MM)	(YYYY/MM)
[ ]	Holder of voting securities over 10 percent	From: ________/________	To: ________/________	(if applicable)
		(YYYY/MM)	(YYYY/MM)