Registration Information Amendments – December 16, 2021 - Annex F – Blackline showing amendments to NI 33-109
Registration Information Amendments – December 16, 2021 - Annex F – Blackline showing amendments to NI 33-109
TABLE OF CONTENTS
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PART 1 -- DEFINITIONS AND INTERPRETATION |
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1.1 |
Definitions |
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1.2 |
Interpretation |
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PART 2 -- APPLICATION FOR REGISTRATION AND REVIEW OF PERMITTED INDIVIDUALS |
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2.1 |
Firm Registration |
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2.2 |
Individual Registration |
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2.3 |
Reinstatement |
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2.4 |
Application to Change or Surrender Individual Registration Categories |
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2.5 |
Permitted Individuals |
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2.6 |
Commodity Futures Act Registrants |
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PART 3 -- CHANGES TO REGISTERED FIRM INFORMATION |
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3.1 |
Notice of Change to a Firm's Information |
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3.2 |
Changes to Business Locations |
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PART 4 -- CHANGES TO REGISTERED INDIVIDUAL AND PERMITTED INDIVIDUAL INFORMATION |
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4.1 |
Notice of Change to an Individual's Information |
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4.2 |
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4.3 |
Updating NRD |
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PART 5 -- DUE DILIGENCE AND RECORD-KEEPING |
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5.1 |
Sponsoring Firm Obligations |
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PART 6 -- [Lapsed] |
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PART 7 -- EXEMPTION |
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7.1 |
Exemption |
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PART 8 -EFFECTIVE DATE |
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8.1 |
[Lapsed] |
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8.2 |
Effective Date |
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FORM 33-109F1 NOTICE OF |
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FORM 33-109F2 CHANGE OR SURRENDER OF INDIVIDUAL CATEGORIES |
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FORM 33-109F3 BUSINESS LOCATIONS OTHER THAN HEAD OFFICE |
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FORM 33-109F4 REGISTRATION OF INDIVIDUALS AND REVIEW OF PERMITTED INDIVIDUALS |
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FORM 33-109F5 CHANGE OF REGISTRATION INFORMATION |
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FORM 33-109F6 FIRM REGISTRATION |
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FORM 33-109F7 REINSTATEMENT OF REGISTERED INDIVIDUALS AND PERMITTED INDIVIDUALS |
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NATIONAL INSTRUMENT 33-109 REGISTRATION INFORMATION
PART 1 -- DEFINITIONS AND INTERPRETATION
1.1 Definitions -- In this Instrument
"business location" means a location where the firm carries out an activity that requires registration, and includes a residence if regular and ongoing activity that requires registration is carried out from the residence or if records relating to an activity that requires registration are kept at the residence;
"cessation date" means the last day on which an individual had authority to act as a registered individual on behalf of their sponsoring firm or was a permitted individual of their sponsoring firm
, because of the end of, or a change in, the individual's employment, partnership, or agency relationship with the firm;"firm" means a person or company that is registered, or is seeking registration, as a dealer, adviser or investment fund manager;
"Form 33-109F1" means Form 33-109F1 Notice of Termination of Registered Individuals and Permitted Individuals;"Form 33-109F1" means Form 33-109F1 Notice of End of Individual Registration or Permitted Individual Status;"Form 33-109F2" means Form 33-109F2 Change or Surrender of Individual Categories;
"Form 33-109F3" means Form 33-109F3 Business Locations other than Head Office;
"Form 33-109F4" means Form 33-109F4 Registration of Individuals and Review of Permitted Individuals;
"Form 33-109F5" means Form 33-109F5 Change of Registration Information;
"Form 33-109F6" means Form 33-109F6 Firm Registration;
"Form 33-109F7" means Form 33-109F7 Reinstatement of Registered Individuals and Permitted Individuals;
"former sponsoring firm" means the registered firm for which an individual most recently acted as a registered individual or permitted individual;
"NRD submission number" means the unique number generated by NRD to identify each NRD submission;
"permitted individual" means
(a) a director, chief executive officer, chief financial officer, or chief operating officer of a firm, or a functional equivalent of any of those positions,
(b) an individual who has beneficial ownership of, or direct or indirect control or direction over, 10 percent or more of the voting securities of a firm; or
(c) a trustee, executor, administrator or other personal or legal representative, that has direct or indirect control or direction over 10 percent or more of the voting securities of a firm;
"principal jurisdiction" means,
(a) for a firm, whose head office is in Canada, the jurisdiction of Canada in which the firm's head office is located,
(b) for an individual whose working office is in Canada, the jurisdiction of Canada in which the individual's working office is located,
(c) for a firm whose head office is outside Canada, the jurisdiction of the firm's principal regulator, as identified by the firm on its most recently submitted Form 33-109F5 or Form 33-109F6, and
(d) for an individual whose working office is outside Canada, the principal jurisdiction of the individual's sponsoring firm;
"principal regulator" means, for a person or company, the securities regulatory authority or regulator of the person or company's principal jurisdiction;
"registered firm" means a registered dealer, registered adviser or registered investment fund manager;
"registered individual" means an individual who is registered under securities legislation to do any of the following on behalf of a registered firm:
(a) act as a dealer, underwriter or adviser;
(b) act as a chief compliance officer;
(c) act as an ultimate designated person;
"sponsoring firm" means,
(a) for a registered individual, the registered firm on whose behalf the individual acts,
(b) for an individual applying for registration, the firm on whose behalf the individual will act if the individual's application is approved,
(c) for a permitted individual of a registered firm, the registered firm, and
(d) for a permitted individual of a firm that is applying for registration, the applicant firm.
1.2 Interpretation -- Terms used in this Instrument and that are defined in National Instrument 31-102 National Registration Database have the same meanings as in National Instrument 31-102 National Registration Database.
PART 2 -- APPLICATION FOR REGISTRATION AND REVIEW OF PERMITTED INDIVIDUALS
2.1 Firm Registration -- A firm that applies for registration as a dealer, adviser or investment fund manager must submit each of the following to the regulator:
(a) a completed Form 33-109F6;
(b) for each business location of the applicant in the local jurisdiction other than the applicant's head office, a completed Form 33-109F3 in accordance with National Instrument 31-102 National Registration Database.
2.2 Individual Registration
(1) Subject to subsection (2) and sections 2.4 and 2.6, an individual who applies for registration under securities legislation must submit a completed Form 33-109F4 to the regulator in accordance with National Instrument 31-102 National Registration Database.
(2) A permitted individual of a registered firm who applies to become a registered individual with the firm must submit a completed Form 33-109F2 to the regulator in accordance with National Instrument 31-102 National Registration Database.
2.3 Reinstatement
(1) An individual who applies for reinstatement of registration under securities legislation must submit a completed Form 33-109F4 to the regulator in accordance with National Instrument 31-102 National Registration Database, unless the individual submits a completed Form 33-109F7 in accordance with subsection (2).
(2) The registration of an individual suspended under section 6.1 [If an individual ceases to have authority to act for firm] of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations is reinstated on the date the individual submits a completed Form 33-109F7 to the regulator in accordance with National Instrument 31-102 National Registration Database if all of the following apply:
(a) the Form 33-109F7 is submitted on or before the 90th day after the cessation date;
(b) the individual's employment, partnership or agency relationship with the former sponsoring firm did not end because the individual was asked by the firm to resign, resigned voluntarily or was dismissed, following an allegation against the individual of any of the following:
(i) criminal activity;
(ii) a breach of securities legislation;
(iii) a breach of a rule of an SRO;(b) in the case of the ceasing to be a registered individual or a permitted individual of the sponsoring firm, at the time of cessation there was no allegation against the individual, in Canada or in any foreign jurisdiction, relevant to an assessment of whether the individual is not suitable for registration or the registration is objectionable, including, for greater certainty, an allegation of any of the following:
(i) a crime;
(ii) a contravention of any statute, regulation or order of a court or regulatory body;
(iii) a contravention of any rule or bylaw of an SRO, of a professional body or of a similar organization;
(iv) a failure to meet any standard of conduct of the sponsoring firm or of any professional body;
(b.1) on or before the cessation date, the individual notified, in accordance with section 4.1, the regulator or, in Québec, the securities regulatory authority of any change to the information previously submitted in the individual's Form 33-109F4;
(b.2) if the Form 33-109F7 is submitted on or after June 6, 2023, on the date Form 33-109F7 is submitted, the individual's information in the National Registration Database does not state "there is no response to this question" for any item of the individual's Form 33-109F4;
(c) after the cessation date there have been no changes to the information previously submitted in respect of any of the following items of the individual's Form 33-109F4:
(i) item 13 [Regulatory disclosure] (other than Item 13.3(a));
(ii) item 14 [Criminal disclosure];
(iii) item 15 [Civil disclosure];
(iv) item 16 [Financial disclosure];
(d) the individual is seeking reinstatement with a sponsoring firm in one or more of the same categories of registration in which the individual was registered on the cessation date;
(e) the new sponsoring firm is registered in the same category of registration in which the individual's former sponsoring firm was registered.
2.4 Application to Change or Surrender Individual Registration Categories -- A registered individual who applies for registration in an additional category, or to surrender a registration category, must make the application by submitting a completed Form 33-109F2 to the regulator in accordance with National Instrument 31-102 National Registration Database.
2.5 Permitted Individuals
(1) A permitted individual must submit a completed Form 33-109F4 to the regulator, in accordance with National Instrument 31-102 National Registration Database, no more than 10 days15 days after becoming a permitted individual, unless the individual submits a Form 33-109F7 in accordance with subsection (2).
(2) An individual who has ceased to be a permitted individual of a former sponsoring firm and becomes a permitted individual of a new sponsoring firm may submit a completed Form 33-109F7 to the regulator if all of the following apply:
(a) the Form 33-109F7 is submitted in accordance with National Instrument 31-102 National Registration Database
(i) no more than
10 days15 days after becoming a permitted individual of the new sponsoring firm, and(ii) no more than 90 days after the cessation date;
(b) the individual holds the same permitted individual status with the new sponsoring firm that they held with the former sponsoring firm;
(c) the conditions described in paragraphs (b) and (c) of subsection 2.3(2) are met.(c) the conditions in paragraphs 2.3(2)(b), (b.1), (b.2) and (c) are met.
2.6 Commodity Futures Act Registrants
(1) In Manitoba and Ontario, despite paragraph 2.1(b), if a firm applies for registration under section 2.1 and is registered under the Commodity Futures Act, the applicant is not required to submit a completed Form 33-109F3 under section 3.2 for any business location of the applicant that is recorded on NRD.
(2) In Manitoba and Ontario, despite subsection 2.2(1), if an individual applies for registration under securities legislation and is recorded on NRD with his or her sponsoring firm as registered under the Commodity Futures Act, the individual must make the application by submitting a completed Form 33-109F2 to the regulator in accordance with National Instrument 31-102 National Registration Database.
PART 3 -- CHANGES TO REGISTERED FIRM INFORMATION
3.1 Notice of Change to a Firm's Information
(1) Subject to subsection (3) or (4), a registered firm must notify the regulator of a change to any information previously submitted in Form 33-109F6 or under this subsection, as follows:
(a) for a change previously submitted in relation to part 3 of Form 33-109F6, within 30 days of the change;
(b) for a change previously submitted in relation to any other part of Form 33-109F6, within 10 days of the change.
(1) In this section, "authorized affiliate" means, in respect of a registered firm, another registered firm that
(a) is an affiliate of the registered firm, and
(b) has the same principal regulator as the registered firm.
(1.1) Subject to subsection (3) or (4), a registered firm must notify the regulator or, in Québec, the securities regulatory authority of a change to any information previously submitted in Form 33-109F6 or under this subsection as follows:
(a) for a change to information previously submitted in relation to any of the following parts or items of Form 33-109F6, within 30 days of the change:
(i) part 3 [Business history and structure];
(ii) item 4.1 [Securities registration];
(iii) item 5.12 [Auditor];
(iv) item 6.1 [Client assets];
(v) item 6.2 [Conflicts of interest];
(b) for a change to information previously submitted in relation to any other part of Form 33-109F6, within 15 days of the change.
(2) A notice of change referred to in subsection (1)subsection (1.1) must be made by submitting a completed Form 33-109F5.
(2.1) A registered firm may delegate to an authorized affiliate the duty to notify the regulator or, in Québec, the securities regulatory authority under subsection (1.1) of a change to information previously submitted if all of the following apply:
(a) the change in information relates only to one or more of the following items or parts of Form 33-109F6:
(i) item 3.12 [Ownership chart];
(ii) item 4.1 [Securities registration];
(iii) item 4.3 [Membership of exchange or SRO];
(iv) item 4.5 [Refusal of registration, licensing or membership];
(v) item 4.6 [Registration for other financial products];
(vi)part 7 [Regulatory action];
(vii) part 8 [Legal action];
(b) the registered firm has filed a certificate, executed by the officer or partner authorized to certify and sign Form 33-109F5, with the registered firm's principal regulator which confirms all of the following:
(i) the registered firm has delegated to the authorized affiliate the duty to notify the regulator or, in Québec, the securities regulatory authority of a change to any information set out in paragraph (a),
(ii) the full legal name and NRD number of the registered firm and the authorized affiliate, and
(iii) that the following certification of the registered firm applies to each notice of change submitted by the authorized affiliate:
"I have read this form and understand all matters within this form, including the questions, and to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete."
(c) the registered firm directs the authorized affiliate to include the full legal name and NRD number of the registered firm and to state the following in each notice of change submitted by the authorized affiliate:
"The registered firm has delegated to the authorized affiliate the duty to notify the regulator or, in Québec, the securities regulatory authority of a change to any of the following items or parts of Form 33-109F6
(i) item 3.12 [Ownership chart];
(ii) item 4.1 [Securities registration];
(iii) item 4.3 [Membership of exchange or SRO];
(iv) item 4.5 [Refusal of registration, licensing or membership];
(v) item 4.6 [Registration for other financial products];
(vi) Part 7 [Regulatory action];
(vii) Part 8 [Legal action]."
(3) A notice of change is not required under subsection (1)subsection (1.1) if the change relates to any of the following:
(a) a business location other than the head office of the firm if the firm submits a completed Form 33-109F3 under section 3.2;
(b) a
terminationcessation, or a change, of a registered firm's employment, partnership or agency relationship with an officer, partner or director of the registered firm if the firm submits a completed Form 33-109F1 under subsection 4.2(1);(c) the addition of an officer, partner, or director to the registered firm if that individual submits either of the following:
(i) a completed Form 33-109F4 under subsection 2.2(1) or 2.5(1);
(ii) a completed Form 33-109F7 under subsection 2.3(2) or 2.5(2);
(d) the information in the supporting documents referred to in any of the following items of Form 33-109F6:
(i) item 3.3 [Business documents];
(ii) item 5.1 [Calculation of excess working capital];
(iii) item 5.7 [Directors' resolution for insurance];
(iv) item 5.13 [Audited financial statements];
(v) item 5.14 [Letter of direction to auditors].
(e) a change in a person or company's ownership of the firm's voting securities referred to in item 3.12 of Form 33-109F6, if the change did not result in the person or company's percentage of ownership falling below or exceeding 10%, 20% or 50% of the firm's voting securities;
(f) a renewal of bonding or insurance referred to in item 5.5 or in item 5.6 of Form 33-109F6, if the bonding or insurance has not lapsed and the only change is the expiry date of the insurance policy to a new date that is at least one year from the previous expiry date.
(4) A person or company that submitted a completed Schedule B an executed Schedule B [Submission to jurisdiction and appointment of agent for service] to Form 33-109F6 must notify the regulator of a change to the information previously submitted in item 3 [Name of agent for service of process] or in item 4 [Address for service of process on the agent for service] of that schedule, by submitting a completed Schedule Ban executed Schedule B no more than 10 days15 days after the change;
(5) Subsection (4) does not apply to a person or company after they have ceased to be registered for a period of 6 years or more.
(6) For the purpose of subsections (2) and (4), the person or company may give the notice by submitting it to the principal regulator.
3.2 Changes to Business Locations -- A registered firm must notify the regulator of the opening of a business location, other than a new head office, or of a change to any information previously submitted in Form 33-109F3, by submitting a completed Form 33-109F3 to the regulator in accordance with National Instrument 31-102 National Registration Database, within 10 days15 days of the opening of the business location or change.
PART 4 -- CHANGES TO REGISTERED INDIVIDUAL AND PERMITTED INDIVIDUAL INFORMATION
4.1 Notice of Change to an Individual's Information
(1) Subject to subsection (2), a registered individual or permitted individual must notify the regulator of a change to any information previously submitted in respect of the individual's Form 33-109F4 as follows:
(a) for a change of information previously submitted in items 4 [Citizenship] and 11 [Previous employment] of Form 33-109F4, within 30 days of the change;
(b) for a change of information previously submitted in any other items of Form 33-109F4, within 10 days of the change.
(1) Subject to subsection (2), a registered individual or permitted individual must notify the regulator or, in Québec, the securities regulatory authority of a change to any information previously submitted in respect of the individual's Form 33-109F4 as follows:
(a) for a change to information previously submitted in any of the following items, within 30 days of the change:
(i) item 2.1 [Current and previous residential addresses];
(ii) item 2.2 [Mailing address];
(iii) item 4 [Citizenship];
(iv) item 10 [Reportable activities];
(v) item 11 [Previous employment and other activities];
(b) for a change to information previously submitted in any other items of Form 33-109F4, within 15 days of the change.
(2) A notice of change is not required under subsection (1) if the change relates to information previously submitted in item 3 [Personal information] of Form 33-109F4.
(2) A notice of change is not required under subsection (1) if the change only relates to any of the following:
(a) information previously submitted in item 3 [Personal information] of Form 33-109F4;
(b) the individual ceasing to have authority to act on behalf of the sponsoring firm as a registered individual or be a permitted individual of the sponsoring firm if a Form 33-109F1 is required to be submitted by the sponsoring firm under subsection 4.2(1).
(3) A notice of change under subsection (1) must be made by submitting a completed Form 33-109F5 to the regulator in accordance with National Instrument 31-102 National Registration Database.
(4) Despite subsection (3), a notice of change referred to in subsection (1) must be made by submitting a completed Form 33-109F2 to the regulator in accordance with National Instrument 31-102 National Registration Database, if the change relates to
(a) an individual's status as a permitted individual of the sponsoring firm,(a) a change in a category of permitted activities of a permitted individual,
(b) the removal or the addition of a category of registration,
(c) the surrender of registration in one or more non-principal jurisdictions, or
(d) any information on Schedule C of Form 33-109F4.
4.2 Termination Cessation of Employment, Partnership or Agency Relationship
(1) A registered firm must notify the regulator of the end of, or a change in, a sponsored individual's employment, partnership, or agency relationship with the firm if the individual ceases to have authority to act on behalf of the firm as a registered individual or permitted individual by submitting a Form 33-109F1 to the regulator in accordance with National Instrument 31-102 National Registration Database with
(a) items 1 through 4 completed, and
(b) item 5 completed unless the reason for termination under item 4 was death of the individual.
(1) A registered firm must notify the regulator or, in Québec, the securities regulatory authority if an individual ceases to have authority to act on behalf of the registered firm as a registered individual or be a permitted individual of the registered firm by submitting Form 33-109F1 to the regulator or, in Québec, the securities regulatory authority in accordance with National Instrument 31-102 National Registration Database with
(a) items 1 to 4 of the Form completed, and
(b) item 5 of the Form completed unless the reason for cessation under item 4 was death of the individual.
(2) A registered firm must submit to the regulator the information required under
(a) paragraph (1)(a), within
10 days15 days of the cessation date, and(b) paragraph (1)(b), within 30 days of the cessation date.
(3) A registered firm must, within 10 days15 days of a request from an individual for whom the registered firm was the former sponsoring firm, provide to the individual a copy of the Form 33-109F1 that the registered firm submitted under subsection (1) in respect of that individual.
(4) If a registered firm completed and submitted the information in item 5 of a Form 33-109F1 in respect of an individual who made a request under subsection (3) and that information was not included in the initial copy provided to the individual, the registered firm must provide to that individual a further copy of the completed Form 33-109F1, including the information in item 5, within the later of
(a)
10 days15 days after the request by the individual under subsection (3), and(b)
10 days15 days after the submission pursuant to paragraph (2)(b).
4.3 Updating NRD -- A registered individual or permitted individual must submit in accordance with National Instrument 31-102 National Registration Database to the regulator or, in Québec, the securities regulatory authority a completed Form 33-109F5 for any item of the individual's Form 33-109F4 in the National Registration Database that states "there is no response to this question" by the earlier of
(a) the date the individual is required to notify the regulator or, in Québec, the securities regulatory authority under subsection 4.1(1) of the first change after June 6, 2022 to any information previously submitted in respect of the individual's Form 33-109F4, and
(b) June 6, 2023.
PART 5 -- DUE DILIGENCE AND RECORD-KEEPING
5.1 Sponsoring Firm Obligations
(1) A sponsoring firm must make reasonable efforts to ensure the truth and completeness of information that is submitted in accordance with this Instrument for any individual.
(2) A sponsoring firm must obtain from each individual who is registered to act on behalf of the firm, or who is a permitted individual of the firm, a copy of the Form 33-109F1 most recently submitted by the individual's former sponsoring firm in respect of that individual, if any, within 60 days of the firm becoming the individual's sponsoring firm.
(3) A sponsoring firm must retain all documents used by the firm to satisfy its obligation under subsection (1) as follows:
(a) in the case of a registered individual, for no less than 7 years after the individual ceases to be registered to act on behalf of the firm;
(b) in the case of an individual who applied for registration but whose registration was refused by the regulator, for no less than 7 years after the individual applied for registration; or
(c) in the case of a permitted individual, for no less than 7 years after the individual ceases to be a permitted individual with the firm.
(4) Without limiting subsection (3), if a registered individual, an individual applying for registration, or a permitted individual 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 (3)(b).
(5) A sponsoring firm that retains a document under subsection (3) or (4) in respect of an NRD submission must record the NRD submission number on the first page of the document.
PART 6 -- [Lapsed]
PART 7 -- EXEMPTION
7.1 Exemption
(1) The regulator or the securities regulatory authority may grant an exemption from this Instrument, in whole or in part, subject to such conditions or restrictions as may be imposed in the exemption.
(2) Despite subsection (1), in Ontario, only the regulator may grant such an exemption.
(3) Except in Alberta and Ontario, an exemption referred to in subsection (1) is granted under the statute referred to in Appendix B of National Instrument 14-101 Definitions, opposite the name of the local jurisdiction.
PART 8 -- REPEAL AND EFFECTIVE DATE
8.1 Repeal -- [Lapsed]
8.2 Effective Date -- This Instrument comes into force on the day National Instrument 31-103 Registration Requirements and Exemptions comes into force.
FORM 33-109F1 NOTICE OF TERMINATION OF REGISTERED INDIVIDUALS AND PERMITTED INDIVIDUALS (section 4.2)
FORM 33-109F1 NOTICE OF END OF INDIVIDUAL REGISTRATION OR PERMITTED INDIVIDUAL STATUS (section 4.2)
WARNING -- It is an offence to knowingly give false or misleading information to the regulator or the securities regulatory authority.
CERTIFICATION
I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm is submitting this form and to any applicable self-regulatory authority (SRO) that
• I have read this form and understand all matters within this form, including the questions, and
• to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete.
NRD format:
[ ] I, the authorized firm representative, am making this submission under authority delegated by the firm. By checking this box, I certify that the firm
(a) provided me with all of the information on this form, and
(b) makes the certification above.
Non-NRD format:
By signing below, I, on behalf of the firm, make the certification above.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed __________ (YYYY/MM/DD)
GENERAL INSTRUCTIONS
Complete and submit this form to notify the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-regulatory organization (SRO) that a registered individual or permitted individual has left their sponsoring firm or has ceased to act in a registerable capacity or as a permitted individual.
Terms
In this form, "cessation date" (or "effective date of termination") means the last day on which an individual had authority to act as a registered individual on behalf of their sponsoring firm or the last day on which an individual was a permitted individual of their sponsoring firm, because of the end of, or a change in, the individual's employment, partnership, or agency relationship with the firm.
As set out in section 1.1 of National Instrument 33-109 Registration Information, "cessation date" means the last day on which an individual had authority to act as a registered individual on behalf of their sponsoring firm or the last day on which an individual was a permitted individual of their sponsoring firm.
How to submit the form
Submit this form at the National Registration Database (NRD) website in NRD format at www.nrd.ca.
If you are relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database, you may submit this form in a format other than NRD format.
When to submit the form
You must submit the responses to Item 1, Item 2, Item 3 and Item 4 within 10 days of the effective date of termination.
If you are required to complete Item 5, you must submit those responses within 30 days of the cessation date. If you are submitting the responses to Item 5, in NRD format, after Items 1 to 4 have been submitted at NRD, use the NRD submission type called "Update/Correct Termination Information" to complete Item 5 of this form.
As set out in paragraph 4.2(2)(a) of National Instrument 33-109 Registration Information, you must submit the responses to Items 1, 2, 3 and 4 within 15 days of the cessation date.
If you are required to complete Item 5, you must submit those responses within 30 days of the cessation date. If you are submitting the responses to Item 5 in NRD format, after Items 1 to 4 have been submitted at NRD, use the NRD submission type called "Update/Correct Cessation Information" to complete Item 5 of this form.
Item 1 Terminating Former sponsoring firm
1. Name ____________________
2. NRD number ____________________
Item 2 Terminated individualIndividual
1. Name ____________________
2. NRD number ____________________
Item 3 Business location of the terminated individual
1. Business location address ____________________
2. NRD number ____________________
Item 4 Date and reason for termination
1. Cessation date / Effective date of termination __________________________ (YYYY/MM/DD)
This is the last day that the individual had authority to act in a registerable capacity on behalf of the firm, or the last day that the individual was a permitted individual.
2. Reason for termination / cessation (check one):
Resigned -- voluntary
[ ]
Resigned -- at the firm's request
[ ]
Dismissed in good standing
[ ]
Dismissed for cause
[ ]
Completed temporary employment contract
[ ]
Retired
[ ]
Deceased
[ ]
Other
[ ]
If "Other", explain:
______________________________
Item 4 Date and reason for cessation
1. Cessation date ____________________ (YYYY/MM/DD)
The above date is the last day on which the individual had authority to act as a registered individual on behalf of the sponsoring firm, or the last day on which the individual was a permitted individual of the sponsoring firm.
2. Reason for cessation (check one):
Resigned -- voluntary
[ ]
Resigned -- at the firm's request
[ ]
Terminated in good standing
[ ]
Terminated for cause
[ ]
Completed temporary employment contract
[ ]
Retired
[ ]
Deceased
[ ]
Other
[ ]
If "Other", explain:
______________________________
Item 5 Details about the terminationcessation
Complete Item 5 except where the individual is deceased. In the space below:
• state the reason(s) for the cessation / termination and
• provide details if the answer to any of the following questions is "Yes".
[For NRD Format only:]
[ ] This information will be disclosed within 30 days of the effective date of termination
[ ] Not applicable: individual is deceased
Complete Item 5 except if the individual is deceased. In the space below
• state the reason(s) for the cessation and
• provide details if the answer to any of the following questions is "Yes".
[For NRD format only:]
[ ] This information will be disclosed within 30 days of the cessation date
[ ] Not applicable: individual is deceased
Answer the following questions to the best of the firm's knowledge.
|
In the past 12 months: |
Yes |
No |
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1. |
Was the individual charged with any criminal offence? |
[ ] |
[ ] |
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2. |
Was the individual the subject of any investigation by any securities or financial industry regulator? |
[ ] |
[ ] |
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3. |
Was the individual subject to any significant internal disciplinary measures at the firm or at any affiliate of the firm related to the individual's activity as a registrant? |
[ ] |
[ ] |
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4. |
Were there any written complaints, civil claims and/or arbitration notices filed against the individual or against the firm about the individual's securities-related activities that occurred while the individual was registered or a permitted individual authorized to act on behalf of the firm? |
[ ] |
[ ] |
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5. |
Does the individual have any undischarged financial obligations to clients of the firm? |
[ ] |
[ ] |
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6. |
Has the firm or any affiliate of the firm suffered significant monetary loss or harm to its reputation as a result of the individual's actions? |
[ ] |
[ ] |
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7. |
Did the firm or any affiliate of the firm investigate the individual relating to possible material violations of fiduciary duties, regulatory requirements or the compliance policies and procedures of the firm or any affiliate of the firm? Examples include making unsuitable trades or investment recommendations, stealing or borrowing client money or securities, hiding losses from clients, forging client signatures, money laundering, deliberately making false representations and engaging in undisclosed |
[ ] |
[ ] |
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8. |
Did the individual repeatedly or materially fail to follow compliance policies and procedures of the firm or any affiliate of the firm? |
[ ] |
[ ] |
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9. |
Did the individual engage in discretionary management of client accounts or otherwise engage in registerable activity without appropriate registration or without the firm's authorization? |
[ ] |
[ ] |
Reasons/Details: ____________________
Item 6 [repealed]
Item 7 Warning[repealed]
It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.
Item 8 Certification[repealed]
Certification -- NRD format:
[ ] I am making this submission as agent for the firm. By checking this box, I certify that the firm provided me with all of the information on this form.
Certification -- Format other than NRD format:
By signing below I certify to the regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form for the firm, either directly or through the principal regulator, that:
• I have read this form and understand the questions, and
• all of the information provided on this form is true and complete.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
Schedule A
[repealed]
FORM 33-109F2 CHANGE OR SURRENDER OF INDIVIDUAL CATEGORIES (section 2.2(2), 2.4, 2.6(2) or 4.1(4))
WARNING -- It is an offence to knowingly give false or misleading information to the regulator or the securities regulatory authority.
CERTIFICATION
Individual
I, the individual, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where I am submitting this form and to any applicable self-regulatory organization (SRO) that
• I have read this form and understand all matters within this form, including the questions,
• I have discussed this form with a branch manager, supervisor, officer or partner of my sponsoring firm and that to the best of my knowledge, the branch manager, supervisor, officer or partner is satisfied that I understand all matters within this form, including the questions,
• to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete, and
• if applicable, I will limit my activities to those allowed by my category of registration and any SRO approval.
I consent to and authorize the collection, directly and indirectly, of personal information by each regulator, securities regulatory authority and SRO and to the use of my personal information as set out in item 6.
Firm
I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm is submitting this form and to any applicable SRO that
• the individual identified in this form will be engaged by the sponsoring firm as a registered individual or a permitted individual, and
• I have, or a branch manager, supervisor, officer or partner has, discussed this form with the individual. To the best of my knowledge, the individual understands all matters within this form, including the questions.
NRD format:
[ ] I, the authorized firm representative, am making this submission under authority delegated by the firm and the individual identified in this form. By checking this box, I certify that
(a) the firm provided me with all of the information on this form and makes the firm certification above,
(b) the individual provided the firm with all of the information on this form and makes the individual certification above, and
(c) the individual provided the above consent and authorization for the collection and use of the individual's personal information.
Non-NRD format:
Individual
By signing below, I, the individual, make the above individual certification and provide my consent and authorization for the collection, directly and indirectly, and use of my personal information.
Signature of individual ____________________
Date signed ____________________ (YYYY/MM/DD)
Firm
By signing below, I, on behalf of the firm, make the firm certification above.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
GENERAL INSTRUCTIONS
Complete and submit this form to notify the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-regulatory organization (SRO) that a registered individual or permitted individual seeks to add and/or remove individual registration categories or permitted activities or provide notice of other changes to the information on Schedule C of Form 33-109F4.
Terms
In this form, "you", "your" and "individual" mean the registered individual or permitted individual who is seeking to add and/or remove registration categories or permitted activities.
How to submit this form
Submit this form at the National Registration Database (NRD) website in NRD format at www.nrd.ca.
If you are relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database, you may submit this form in a format other than NRD format.
Item 1 Individual
Name of individual ____________________
NRD number of individual ____________________
Item 2 Registration jurisdictions
1. Are you filing this form under the passport system / interface for registration?
Choose "No" if you are registered in:
(a) only one jurisdiction of Canada
(b) more than one jurisdiction of Canada and you are requesting a surrender in a non-principal jurisdiction or jurisdictions, but not in your principal jurisdiction, or
(c) more than one jurisdiction of Canada and you are requesting a change only in your principal jurisdiction.
Yes
[ ]
No
[ ]
2. Check each jurisdiction where you are seeking the change or surrender.
[ ] Alberta
[ ] British Columbia
[ ] Manitoba
[ ] New Brunswick
[ ] Newfoundland and Labrador
[ ] Northwest Territories
[ ] Nova Scotia
[ ] Nunavut
[ ] Ontario
[ ] Prince Edward Island
[ ] Québec
[ ] Saskatchewan
[ ] Yukon
Item 3 Removing categories
What categories are you seeking to remove?
______________________________
Item 4 Adding categories
1. Categories
What categories are you seeking to add?
______________________________
2. Professional liability insurance (Québec mutual fund dealers and Québec scholarship plan dealers)
If you are seeking registration as a representative of a mutual fund dealer or of a scholarship plan dealer in Québec, are you covered by your sponsoring firm's professional liability insurance?
|
Yes |
[ ] |
No |
[ ] |
If "No", state:
The name of your insurer ____________________
Your policy number ____________________
3. Relevant securities industry experience
If you have not been registered in the last 36 months and you passed the required examination more than 36 months ago, do you consider that you have gained 12 months of relevant securities industry experience during the 36-month period?
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|
If you are an individual applying for IIROC approval, select "N/A".
If "Yes", complete Schedule A.
Do you have securities experience?
|
Yes |
[ ] |
No |
[ ] |
N/A |
[ ] |
If you are an individual applying for IIROC approval, select "N/A".
If "Yes", complete Schedule A.
Item 5 Reason for surrender
If you are seeking to remove a registration category or permitted activity, state the reason for the surrender in the local jurisdiction.
______________________________
Item 6 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 in the jurisdictions set out in Schedule B to administer and enforce certain provisions of their securities legislation or derivatives legislation or both.
The personal information required under this form is also collected by and used by the SRO set out in Schedule B to administer and enforce its by-laws, regulations, rules, rulings and policies.
By submitting this form, the individual consents to the collection by the securities regulatory authorities or applicable SRO of this personal information, and any police records, records from other government or non-governmental regulators or SROs, credit records and employment records about the individual that the securities regulatory authorities or applicable SRO may need to complete their review of the information submitted in this form relating to the individual's continued fitness for registration or approval, if applicable, in accordance with the legal authority of the securities regulatory authorities while the individual is registered with or approved by it. Securities regulatory authorities or SROs may contact government and private bodies or agencies, individuals, corporations and other organizations for information about the individual.
If you have any questions about the collection and use of this information, contact the securities regulatory authorities or applicable SRO in any jurisdiction in which the required information is submitted. See Schedule B for details. In Québec, you can also contact the Commission d'accès à l'information at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca.
Item 6 Notice and consent for collection and use of personal information
1. Notice of collection and use of personal information
Your personal information is collected by, or on behalf of, each securities regulatory authority and SRO set out in Schedule B. Any of the securities regulatory authorities or SROs set out in Schedule B may contact governmental or regulatory authorities, private bodies or agencies, individuals, corporations, employers, and other organizations, in Canada and in other countries, for information about you.
This personal information is being collected under the authority of the applicable securities legislation, derivatives legislation (including commodity futures legislation) or both of the securities regulatory authorities and under the SRO rules of an SRO set out in Schedule B. The collection, use and disclosure are done in accordance with applicable freedom of information and privacy legislation.
The principal purpose of this collection by the securities regulatory authorities is to administer, enforce, carry out their duties or exercise their powers under their respective securities legislation, derivatives legislation (including commodity futures legislation) or both, and by the SROs to administer and enforce the rules of the SROs.
The information submitted by you on this form with your consent, or collected indirectly with your authorization, may be collected
• at any time during your registration or while you are a permitted individual, or
• at the time the regulator or, in Québec, the securities regulatory authority, or the SRO is informed by your sponsoring firm that you no longer have authority to act on behalf of the sponsoring firm or are not a permitted individual of the sponsoring firm.
If you have any questions about the collection, use and disclosure of this information, contact the securities regulatory authority or SRO in any jurisdiction in which the required information is submitted. See Schedule B for details.
Certain information, such as your name(s) (including aliases, trade names or some past names), your sponsoring firm, and other relevant registration information, will be listed in a publicly available registry of registered individuals and, if applicable, on the Disciplined List.
Certain securities regulatory authorities may provide to or receive from certain entities information under separate provisions of their securities legislation or derivatives legislation (including commodity futures legislation) or both, and SROs may provide or receive information under the rules of the SROs. This consent and notice does not limit the authority, powers, obligations, or rights conferred on any of the securities regulatory authorities by legislation or regulations in effect in their jurisdiction.
2. Consent to collect and use personal information
By submitting this form, you consent to and authorize the collection, directly and indirectly, of personal information by each securities regulatory authority and SRO and to the use of your personal information as set out above.
The personal information that each securities regulatory authority or SRO collects includes the following:
• the personal information provided in this form;
• the personal information provided by your sponsoring firm;
• registration or financial services licensing information;
• law enforcement records, including police records;
• credit records;
• bankruptcy or other insolvency records;
• employment records and information received from an employer;
• records and information received from entities you had or have an independent contractor or agency relationship with;
• personal information available online;
• records from governmental or regulatory authorities, SROs or professional bodies;
• records of, and used in, court proceedings, including probation records.
Item 7 Warning[repealed]
It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.
Item 8 Certification[repealed]
Certification -- NRD format:
I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm. To the best of my knowledge and belief, the officer, branch manager or supervisor was satisfied that I fully understood the questions. I will limit my activities to those permitted by my category of registration.
[ ] I am making this submission as agent for the individual identified in this form. By checking this box, I certify that the individual provided me with all of the information on this form.
Certification -- Format other than NRD format:
By signing below:
1. I certify to the regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form, either directly or through the principal regulator, that:
• I have read this form and understand the questions, and
• all of the information provided on this form is true, and complete.
2. I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm. To the best of my knowledge and belief, the officer, branch manager or supervisor was satisfied that I fully understood the questions. I will limit my activities to those permitted by my category of registration.
Signature of individual ____________________
Date signed ____________________ (YYYY/MM/DD)
By signing below, I certify to the regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form for the individual, either directly or through the principal regulator, that:
1. the individual identified in this form will be engaged by the firm as a registered individual, or a non registered individual, and
2. I have, or a branch manager or supervisor or another officer or partner has, discussed the questions set out in this form with the individual. To the best of my knowledge and belief, the individual fully understands the questions.
Name of firm ____________________
Name of authorized signing officer or partner
______________________________
Title of authorized signing officer or partner
______________________________
Signature of authorized signing officer or partner
______________________________
Date signed (YYYY/MM/DD)
Schedule A Relevant securities industry experience (Item 4)
Describe your responsibilities in areas relating to the category you are applying for, including the title(s) you have held, as well as start and end dates:
______________________________
______________________________
______________________________
What is the percentage of your time devoted to these activities?
_____ %
Indicate the continuing education activities in which you have participated during the last 36 months and that are relevant to the category of registration you are applying for:
______________________________
______________________________
______________________________
Schedule A Relevant securities experience (Item 4)
Instructions:
• Some registration categories require a specified amount of experience to have been obtained within specified timeframes. Please see National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations or the relevant SRO rules for more information.
• If you are applying to be an advising representative or an associate advising representative, or with IIROC as a portfolio manager, associate portfolio manager, or supervisor designated to be responsible for the supervision of managed accounts, provide details of the activities you performed for each position in which you gained relevant investment management experience. Such details may include the level of responsibility; value of accounts under direct supervision; number of years of experience in performing securities research and analysis for the purpose of portfolio securities selection, portfolio construction and analysis; type of experience in performing client relationship management; number of years of experience collecting know-your-client information; or number of years of experience conducting suitability assessments.
• If you are applying as an advising representative limited to client relationship management, indicate this by including the following statement: "Individual seeking registration as CRM AR".
• For all other categories, provide details of activities that you performed for each position in which you gained relevant securities industry experience.
1. If you are applying
• to be an advising representative or an associate advising representative of a portfolio manager, describe the relevant investment management experience that you have gained, or
• for any other category, describe the relevant securities industry experience that you have gained.
For each position in which you gained relevant experience, provide the following information:
(a) the name of the firm or entity with which you gained this experience;
(b) your title;
(c) the start and end dates of this position;
(d) the details of the activities you performed that are relevant for the category of registration that you are applying for;
(e) the percentage of your time in this position that was spent on activities relating to the experience.
______________________________
______________________________
______________________________
2. Indicate the continuing education activities in which you have participated during the last 36 months and that are relevant to the category of registration you are applying for:
______________________________
______________________________
______________________________
Schedule B Contact information for Notice of notice and consent for collection and use of personal information
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Alberta |
Nunavut |
|
Alberta Securities Commission, |
Government of Nunavut |
|
Suite 600, 250-5th St. SW |
Department of Justice |
|
Calgary, AB T2P 0R4 |
P.O. Box 1000 Station 570 |
|
Attention: Information Officer |
Iqaluit, NU X0A 0H0 |
|
Telephone: (403) 297-6454 |
Attention: Deputy Registrar of Securities |
|
Telephone: (867) 975-6590 |
|
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British Columbia |
Ontario |
|
British Columbia Securities Commission |
Ontario Securities Commission |
|
P.O. Box 10142, Pacific Centre |
22nd Floor |
|
701 West Georgia Street |
20 Queen Street West |
|
Vancouver, BC V7Y 1L2 |
Toronto, ON M5H 3S8 |
|
Attention: |
Attention: Compliance and Registrant Regulation |
|
Telephone: (604) 899-6500 or (800) 373-6393 (in Canada) |
Telephone: (416) 593-8314 |
|
E-mail: [email protected] |
E-mail: [email protected] |
|
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Manitoba |
Prince Edward Island |
|
The Manitoba Securities Commission |
Securities Office |
|
500 -- 400 St. Mary Avenue |
Department of Community Affairs and Attorney General |
|
Winnipeg, MB R3C 4K5 |
P.O. Box 2000 |
|
Attention: Director of Registrations |
Charlottetown, PE C1A 7N8 |
|
Telephone: (204) 945-2548 |
Attention: Deputy Registrar of Securities |
|
Fax (204) 945-0330 |
Telephone: (902) 368-6288 |
|
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|
New Brunswick |
Québec |
|
Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick |
Autorité des marchés financiers |
|
Suite 300, 85 Charlotte Street |
800, square Victoria, 22e étage |
|
Saint John, NB E2L 2J2 |
C.P. 246, tour de la Bourse |
|
Attention: Director of Securities |
Montréal (Québec) H4Z 1G3 |
|
Telephone: (506) 658-3060 |
Attention: Responsable de l'accès à l'information |
|
Telephone: (514) 395-0337 or (877) 525-0337 |
|
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Newfoundland and Labrador |
Saskatchewan |
|
Superintendent of Securities, Service NL |
Financial and Consumer Affairs Authority of Saskatchewan |
|
Government of Newfoundland and Labrador |
Suite 601, 1919 Saskatchewan Drive |
|
P.O. Box 8700 |
Regina, SK S4P 4H2 |
|
2nd Floor, West Block |
Attention: |
|
Confederation Building |
Telephone: (306) 787-5871 |
|
St. John's, NL A1B 4J6 |
E-mail: [email protected] |
|
Attention: Manager of Registrations |
|
|
Telephone: (709) 729-5661 |
|
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|
Nova Scotia |
Yukon |
|
Nova Scotia Securities Commission |
Government of Yukon |
|
Suite 400, 5251 Duke Street |
Department of Community Services |
|
Halifax, NS B3J 1P3 |
P.O. Box 2703 C-6 |
|
Attention: |
Whitehorse, YT Y1A 2C6 |
|
Telephone: (902) 424-7768 |
Attention: Superintendent of Securities |
|
Telephone: |
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Northwest Territories |
Self-regulatory organization |
|
Government of the Northwest Territories |
Investment Industry Regulatory Organization of Canada |
|
Department of Justice |
121 King Street West, Suite 2000 |
|
1st Floor Stuart M. Hodgson Building |
Toronto, Ontario M5H 3T9 |
|
5009 -- 49th Street |
Attention: Privacy Officer |
|
Yellowknife, NWT X1A 2L9 |
Telephone: (416) 364-6133 |
|
Attention: |
E-mail: [email protected] |
|
Telephone: (867) 920-8984 |
|
FORM 33-109F3 BUSINESS LOCATIONS OTHER THAN HEAD OFFICE (section 3.2)
WARNING -- It is an offence to knowingly give false or misleading information to the regulator or the securities regulatory authority.
CERTIFICATION
I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm is submitting this form and to any applicable self-regulatory organization (SRO) that
• I have read this form and understand all matters within this form, including the questions,
• if the business location specified in this form is a residence, the individual conducting business from that business location has completed a Form 33-109F4 Registration of Individuals and Review of Permitted Individuals, and
• to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete.
NRD format:
[ ] I, the authorized firm representative, am making this submission under authority delegated by the firm.
[ ] By checking this box, I, the authorized firm representative, certify that
(a) the firm provided me with all of the information on this form, and
(b) the firm makes the certification above.
Non-NRD format:
By signing below, I, on behalf of the firm, make the certification above.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
GENERAL INSTRUCTIONS
Complete and submit this form to notify the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-regulatory organization (SRO) that a business location has opened or closed, or information about a business location has changed.
Check one of the following and complete the entire form:
[ ] Opening this business location
[ ] Closing this business location
[ ] Change to the information previously submitted about this business location. Clearly specify the information that has changed.
How to submit this form
Submit this form at the National Registration Database (NRD) website in NRD format at www.nrd.ca.
If you are relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database, you may complete and submit this form in a format other than NRD format.
Item 1 Type of business location
Branch or business location [ ]
Sub-branch (Mutual Fund Dealers Association of Canada members only) [ ]
Item 2 Supervisor or branch manager
Name of designated supervisor or branch manager ____________________
NRD number of the designated supervisor or branch manager ____________________
Item 3 Business location information
Business location address ____________________ (a post office box is not a valid business location address)
Mailing address (if different from business location address) ____________________
Telephone number (_____) __________________
Fax number (_____) _______________________
E-mail address ____________________________
Notice regarding a business location that is a residence
For the administration of securities legislation or derivatives legislation, including commodity futures legislation, or both, the regulator or, in Québec, the securities regulatory authority may require access to the business location to review the books, records and documents of the registered firm. If applicable, the SRO may also require access to the business location for the administration of the rules of the SRO.
If the business location specified in this form is a residence, the regulator, securities regulatory authority or SRO may request consent to enter the residence.
If consent is not provided, it may affect the ability of the regulator, securities regulatory authority or SRO to access the books, records or documents of a registered firm and to determine whether securities legislation, derivatives legislation (including commodity futures legislation) or the rules of the SRO are being complied with. As a result, the regulator, securities regulatory authority or SRO may take action if it is unable to access and review the books, records or documents of a registered firm held at the business location.
Item 4 Notice of collection and use of personal information[repealed]
The personal information required under this form is collected on behalf of, and used by, the securities regulatory authorities in the jurisdictions set out in Schedule A to administer and enforce certain provisions of their securities legislation or derivatives legislation or both.
The personal information required under this form is also collected by and used by the SRO set out in Schedule A to administer and enforce its by-laws, regulations, rules, rulings and policies.
By submitting this form, the individual consents to the collection by the securities regulatory authorities or applicable SRO of this personal information, and any police records, records from other government or non-governmental regulators or SROs, credit records and employment records about the individual that the securities regulatory authorities or applicable SRO may need to complete their review of the information submitted in this form relating to the individual's continued fitness for registration or approval, if applicable, in accordance with the legal authority of the securities regulatory authorities while the individual is registered with or approved by it. Securities regulatory authorities or SROs may contact government and private bodies or agencies, individuals, corporations and other organizations for information about the individual.
If you have any questions about the collection and use of this information, contact the securities regulatory authorities or applicable SRO in any jurisdiction in which the required information is submitted. See Schedule A for details. In Québec, you can also contact the Commission d'accès à l'information at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca.
Item 5 Warning[repealed]
It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.
Item 6 Certification[repealed]
Certification -- NRD format:
[ ] I am making this submission as agent for the firm. By checking this box, I certify that the firm provided me with all of the information on this form.
[ ] If the business location is a residence, the individual conducting business from that business location has completed a Form 33-109F4 Registration of Individuals and Review of Permitted Individuals certifying that they give their consent for the regulator or, in Québec, the securities regulatory authority to enter the residence for the administration of securities legislation and derivatives legislation, including commodity futures legislation.
Certification -- Format other than NRD format:
By signing below, I certify to the securities regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form for the firm, either directly or through the principal regulator, that:
• I have read this form and understand the questions,
• all of the information provided on this form is true, and complete, and
• if the business location specified in this form is a residence, the individual conducting business from that business location has completed a Form 33-109F4 Registration of Individuals and Review of Permitted Individuals certifying that they give their consent for the regulator or, in Québec, the securities regulatory authority to enter the residence for the administration of securities legislation and derivatives legislation, including commodity futures legislation.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
Schedule A [repealed] Contact information for Notice of collection and use of personal information
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FORM 33-109F4 REGISTRATION OF INDIVIDUALS AND REVIEW OF PERMITTED INDIVIDUALS (section 2.2)
WARNING -- It is an offence to knowingly give false or misleading information to the regulator or the securities regulatory authority.
CERTIFICATION
Individual
I, the individual, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where I am submitting this form and to any applicable self-regulatory organization (SRO) that
• I have read this form and understand all matters within this form, including the questions and, for greater certainty, if the business location is a residence, the notice in Item 9,
• I have discussed this form with a branch manager, supervisor, officer or partner of my sponsoring firm and that to the best of my knowledge, the branch manager, supervisor, officer or partner is satisfied that I understand all matters within this form, including the questions,
• to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete, and
• if applicable, I will limit my activities to those allowed by my category of registration and any SRO approval.
I consent to and authorize the collection, directly and indirectly, of personal information by each regulator, securities regulatory authority and SRO and to the use of my personal information as set out in Item 20.
Firm
I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm is submitting this form and to any applicable SRO that
• the individual identified in this form will be engaged by the sponsoring firm as a registered individual or a permitted individual, and
• I have, or a branch manager, supervisor, officer or partner has, discussed this form with the individual. To the best of my knowledge, the individual understands all matters within this form, including the questions.
NRD format:
[ ] I, the authorized firm representative, am making this submission under authority delegated by the firm and the individual identified in this form. By checking this box, I certify that
(a) the firm provided me with all of the information on this form and makes the firm certification above,
(b) the individual provided the firm with all of the information on this form and makes the individual certification above, and
(c) the individual provided the above consent and authorization for the collection and use of the individual's personal information.
Non-NRD format:
Individual
By signing below, I, the individual, make the above individual certification and provide my consent and authorization for the collection, directly and indirectly, and use of my personal information.
Signature of individual ____________________
Date signed ____________________ (YYYY/MM/DD)
Firm
By signing below, I, on behalf of the firm, make the firm certification above.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
GENERAL INSTRUCTIONS
Complete and submit this form to the relevant regulator(s) or in Québec, the securities regulatory authority, or self-regulatory organization (SRO) if an individual is seeking
• registration in individual categories,
• to be reviewed as a permitted individual.
You are only required to submit one form even if you are applying to be registered in several categories. This form is also used if you are seeking to be reviewed as a permitted individual. A post office box is not acceptable as a valid business location address.
Terms
In this form:
"Approved person" means, in respect of a member (Member) of the Investment Industry Regulatory Organization of Canada (IIROC), an individual who is a partner, director, officer, employee or agent of a Member who is approved by IIROC or another Canadian SRO to perform any function required under any IIROC or another Canadian SRO by-law, rule, or policy;
"Canadian Investment Manager designation" means the designation earned through the Canadian investment manager program prepared and administered by CSI Global Education Inc. and so named on the day this Instrument comes into force, and every program that preceded that program, or succeeded that program, that does not have a significantly reduced scope and content when compared to the scope and content of the first-mentioned program;
"CFA Charter" means the charter earned through the Chartered Financial Analyst program prepared and administered by the CFA Institute and so named on the day this Instrument comes into force, and every program that preceded that program, or succeeded that program, that does not have a significantly reduced scope and content when compared to the scope and content of the first-mentioned program;
"Derivatives" means financial instruments, such as futures contracts (including exchange traded contracts), futures options and swaps whose market price, value or payment obligations are derived from, or based on, one or more underlying interests. Derivatives can be in the form of instruments, agreements or securities;
"Major shareholder" and "shareholder" mean a shareholder who, in total, directly or indirectly owns voting securities carrying 10 per cent or more of the votes carried by all outstanding voting securities;
"Sponsoring firm" means the registered firm where you will carry out your duties as a registered or permitted individual; and
"You", "your" and "individual" mean the individual who is seeking registration or the individual who is filing this form as a permitted individual under securities legislation or derivatives legislation or both.
How to submit this form
NRD format
Submit this form at the National Registration Database (NRD) website in NRD format at www.nrd.ca. If you have any questions, contact the compliance, registration or legal department of the sponsoring firm or a legal adviser with securities law experience, or visit the NRD information website at www.nrd-info.ca.
Format, other than NRD format
If you are relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database, you may submit this form in a format other than NRD format.
If you need more space, use a separate sheet of paper. Clearly identify the item and question number. Complete and sign the form, and send it to the relevant regulator(s) or, in Québec, the securities regulatory authority, SRO(s) or similar authority. The number of originally signed copies of the form you are required to submit depends on the province or territory, and on the regulator, the securities regulatory authority or SRO.
To avoid delays in processing this form, be sure to answer all of the questions that apply to you. If you have questions, contact the compliance, registration or legal department of the sponsoring firm or a legal adviser with securities law experience, or visit the NRD information website at www.nrd-info.ca.
Item 1 Name
1. Legal name
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__________ |
__________ |
__________ |
__________ |
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Last name |
First name |
Second name (N/A [ ]) |
Third name (N/A [ ]) |
NRD number (if applicable) ____________________
2. Other personal names
Are you currently, or have you ever been, known by any names other than your full legal name above, for example, nicknames or names due to marriage?
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Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule A.
3. Use of other names
Are you currently, or have you ever used, operated under, or carried on business under any name other than the name(s) mentioned above, for example, trade names for sole proprietorships or team names?
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Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule A.
Item 2 Residential address
Provide all of your residential addresses, including any foreign residential addresses, for the past 10 years.
1. Current and previous residential addresses
____________________ (number, street, city, province, territory or state, country, postal code)
Telephone number ____________________
Lived at this address since (YYYY/MM) ____________________
If you have lived at this address for less than 10 years, complete Schedule B.
2. Mailing address
[ ] Check here if your mailing address is the same as your current residential address provided above. Otherwise, complete the following:
____________________ (number, street, city, province, territory or state, country, postal code)
______________________________
3. Business e-mail address
______________________________
Item 3 Personal information
1. Date of birth ____________________ (YYYY/MM/DD)
2. Place of birth ____________________ (city, province, territory or state, country)
3. Gender Female [ ] Male [ ]
4. Eye colour ____________________
5. Hair colour ____________________
6. Height ________ in. or ________ [ ] cm
7. Weight _______ lbs. or ________ [ ] kg
Item 4 Citizenship
1. Citizenship information
What is your country of citizenship?
[ ] Canada
[ ] Other, specify: __________________
2. If you are a citizen of a country other than Canada, complete the following for that citizenship.
[ ] Check here if you do not have a valid passport. Otherwise, provide:
Passport number: ____________________
Date of issue: ____________________ (YYYY/MM/DD)
Place of issue: ____________________ (city, province, territory or state, country)
Item 5 Registration jurisdictions
1. Are you filing this form under the passport system / interface for registration?
Only choose "No" if:
(a) you are seeking registration only in your principal jurisdiction,
(b) you are seeking review as a permitted individual
and you are not currently registered under securities legislation in any jurisdiction of Canada.
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Yes |
[ ] |
No |
[ ] |
2. Check each jurisdiction where you are seeking registration or review as a permitted individual:
[ ] All jurisdictions
[ ] Alberta
[ ] British Columbia
[ ] Manitoba
[ ] New Brunswick
[ ] Newfoundland and Labrador
[ ] Northwest Territories
[ ] Nova Scotia
[ ] Nunavut
[ ] Ontario
[ ] Prince Edward Island
[ ] Québec
[ ] Saskatchewan
[ ] Yukon
2. Check each jurisdiction where you are seeking registration or, if you are seeking review as a permitted individual, check each jurisdiction where your sponsoring firm is registered:
[ ] All jurisdictions
[ ] Alberta
[ ] British Columbia
[ ] Manitoba
[ ] New Brunswick
[ ] Newfoundland and Labrador
[ ] Northwest Territories
[ ] Nova Scotia
[ ] Nunavut
[ ] Ontario
[ ] Prince Edward Island
[ ] Québec
[ ] Saskatchewan
[ ] Yukon
Item 6 Individual categories
1. On Schedule C, check each category for which you are seeking registration as an individual or review as a permitted individual. If you are seeking review as a permitted individual, check each category that describes your position with your sponsoring firm.
2. If you are seeking registration as a representative of a mutual fund dealer or of a scholarship plan dealer in Québec, are you covered by your sponsoring firm's professional liability insurance?
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Yes |
[ ] |
No |
[ ] |
If "No", state:
The name of your insurer ____________________
Your policy number ____________________
Item 7 Address and agent for service
1. Address for service
You must have one address for service in each province or territory where you are submitting this form. A residential address or a business address is acceptable. 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, if applicable ____________________
Business e-mail address
______________________________
2. Agent for service
If you have appointed an agent for service, provide the following information for the agent in each province or territory where you have an agent for service. The address of your agent for service must be the same as the address for service above. If your agent for service is not an individual, provide the name of your contact person.
Name of agent for service: ____________________
Contact person: ____________________ Last name, First name
Item 8 Proficiency
1. Course, examination or designation information and other education
Complete Schedule E to indicate each course, examination and designation that is required for registration or approval and that you have successfully completed or have been exempted from.
[ ] Check here if you are not required under securities legislation or derivatives legislation or both, or the rules of an SRO to satisfy any course, examination or designation requirements.
Complete Schedule E to state each course, examination and designation that
• is required for the registration categories or SRO approval categories you are applying for, and
• you have successfully completed or, if you are an IIROC applicant, have been exempted from.
[ ] Check here if you are not required under securities legislation or derivatives legislation (including commodity futures legislation), or the rules of an SRO, to satisfy any course, examination or designation requirements.
2. Student numbers
If you have a student number for a course that you successfully completed with one of the following organizations, provide it below:
CSI Global Education: ____________________
IFSE Institute: ____________________
Institute of Canadian Bankers (ICB): ____________________
CFA Institute: ____________________
Advocis: ____________________
RESP Dealers Association of Canada: ____________________
Other: ____________________
3. Exemption refusal
Has any securities regulator, derivatives regulator or SRO refused to grant you an exemption from a course, examination, designation or experience requirement?
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Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule F.
4. Relevant securities industry experience
If you are an individual applying for IIROC approval, select "N/A".
If you have not been registered in the last 36 months and you passed the required examination more than 36 months ago, do you consider that you have gained 12 months of relevant securities industry experience during the 36-month period?
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If "Yes", complete Schedule F.
If you are an individual applying for IIROC approval, select "N/A".
Do you have relevant securities experience?
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Yes |
[ ] |
No |
[ ] |
N/A |
[ ] |
If "Yes", complete Schedule F.
Item 9 Location of employment
1. Provide the following information for your new sponsoring firm. If you will be working out of more than one business location, provide the following information for the business location out of which you will be doing most of your business. If you are only filing this form because you are a permitted individual and you are not employed by, or acting as agent for, the sponsoring firm, select "N/A".
NRD location number: ____________________
Unique Identification Number (optional): ____________________
Business location address: ____________________ (number, street, city, province, territory or state, country, postal code)
Telephone number: (___) ____________________
Fax number: (___) ____________________
N/A [ ]
2. If the firm has a foreign head office, and/or you are not a resident of Canada, provide the address for the business location in which you will be conducting most of your business. If you are only filing this form because you are a permitted individual and you are not employed by, or acting as agent for, the sponsoring firm, select "N/A".
Business location address: ____________________ (number, street, city, province, territory or state, country, postal code)
Telephone number: (___) ____________________
Fax number: (___) ____________________
N/A [ ]
[The following under #3 "Type of business location", #4 and #5 is for a format other than NRD format only]
3. Type of business location:
[ ] Head office
[ ] Branch or business location
[ ] Sub-branch (members of the Mutual Fund Dealers Association of Canada only)
4. Name of supervisor or branch manager: ________________________
5. Check here if the mailing address of the business location is the same as the business location address provided above. Otherwise, complete the following:
Mailing address: ____________________ (number, street, city, province, territory or state, country, postal code)
6. Notice regarding a business location that is a residence
For the administration of securities legislation or derivatives legislation, including commodity futures legislation, or both, the regulator or, in Québec, the securities regulatory authority may require access to the business location to review the books, records and documents of the registered firm. If applicable, the SRO may also require access to the business location for the administration of the rules of the SRO.
If the business location specified in this form is a residence, the regulator, securities regulatory authority or SRO may request consent to enter the residence.
If consent is not provided, it may affect the ability of the regulator, securities regulatory authority or SRO to access the books, records or documents of a registered firm and to determine whether securities legislation, derivatives legislation (including commodity futures legislation) or the rules of the SRO are being complied with. As a result, the regulator, securities regulatory authority or SRO may take action if it is unable to access and review the books, records or documents of a registered firm held at the business location.
Item 10 Current employment, other business activities, officer positions held and directorships
Complete a separate Schedule G for each of your current business and employment activities, including employment and business activities with your sponsoring firm and any employment and business activities outside your sponsoring firm. Also include all officer or director positions and any other equivalent positions held, as well as positions of influence. The information must be provided
• whether or not you receive compensation for such services, and
• whether or not any such position is business related.
Item 10 Reportable activities
1. Activities with your sponsoring firm
Instructions: Describe all of your roles and responsibilities with your sponsoring firm, whether these roles and responsibilities are securities-related or not (e.g., sale of securities, review of marketing materials, IT help desk, negotiation of employment contracts, sales of banking and insurance products and services). Include any other information about your position with your sponsoring firm that is relevant for the regulator or, in Québec, the securities regulatory authority to know (e.g., if your role is specialized). For example, if you are applying as an advising representative limited to client relationship management, indicate this by including the following statement in Schedule G: "Individual is seeking registration as CRM AR."
Complete a Schedule G with respect to your roles and responsibilities with your sponsoring firm.
2. Reportable outside activities
Instructions: Consider all of the activities that you participate in outside of your sponsoring firm, whether or not you receive compensation for such activities and whether or not any such activity is business-related. Activities performed for an affiliated entity are considered activities outside of your sponsoring firm. If any of the categories below describes one or more activities that you participate in, complete a separate Schedule G for each activity or entity. If multiple activities are performed for one entity, complete a single Schedule G identifying all the activities performed.
Uncompensated activities that do not fall within Categories 1 to 5 (i.e., generally activities that do not involve securities or financial services and are not a position of influence, such as being a little league soccer coach) are not reportable.
Category 1 -- Activities with another registered firm
Instructions: Report activities with registered firms, other than your sponsoring firm. All activities in this category are reportable, whether or not you receive compensation for such activities. Major shareholder means a shareholder who, in total, directly or indirectly owns voting securities carrying 10 percent or more of the votes carried by all outstanding voting securities.
If you are a director, officer, employee, contractor, consultant, agent, or service provider of a registered firm other than your sponsoring firm, or are in any other equivalent position with or for that registered firm, or are a major shareholder or partner of that registered firm, complete a separate Schedule G for the registered firm.
Category 2 -- Activities with an entity that receives compensation from a registered firm
If you are a director, officer, employee, contractor, consultant, or agent of a specified entity, or are in any other equivalent position with or for a specified entity, or are a shareholder or partner of a specified entity, complete a separate Schedule G for the specified entity.
For the purposes of this category, "specified entity" means an entity that receives compensation from a registered firm for activities that you provide for your sponsoring firm or another registered firm.
Category 3 -- Other securities-related activities
Instructions: All activities in this category are reportable, whether or not you receive compensation for such activities. Charitable or other fundraising activities that do not involve the issuance of securities or derivatives are not reportable.
If you have been at any time in the last 7 years directly involved in raising money for an entity through the issuance of securities or derivatives or promoting the sale of an entity's securities or derivatives outside of your activities with your sponsoring firm or another registered firm, complete a separate Schedule G for each entity for which you performed these activities.
Directors and officers of reporting issuers and of entities that have been at any time in the last 7 years raising money through the issuance of securities or derivatives are considered to be directly involved in raising money for that entity.
Category 4 -- Provision of financial or finance-related services
Instructions: All activities in this category are reportable, whether or not you receive compensation for such activities. For example, volunteer activities pertaining to your securities or financial services knowledge must be reported under this category. Also report if you are the owner or management of an entity that provides these services. Major shareholder means a shareholder who, in total, directly or indirectly owns voting securities carrying 10 percent or more of the votes carried by all outstanding voting securities.
Complete a separate Schedule G for each activity, as applicable, if you
• sell or negotiate insurance, including being an insurance broker or agent,
• provide loan or deposit or other banking products and services,
• carry on a money service business, including exchanging one type of currency for another, transferring money from one person to another, or issuing or redeeming money orders, traveller's cheques or anything similar,
• facilitate or administer mortgages, including acting as a mortgage broker, agent or administrator,
• prepare tax returns or provide tax advice,
• help create programs for persons to meet their long-term financial goals, including providing financial planning (including estate planning) or financial advice,
• provide corporate finance services, including services provided in the capacity of a comptroller, treasurer and chief financial officer,
• advise persons under financial stress on credit/debt restructuring,
• are a pension consultant,
• provide advice on mergers and acquisitions,
• provide accounting or bookkeeping services,
• provide oversight or independent review or expert opinion on the management of an entity's financial assets,
• lend money or accept deposits of money (e.g., alternative financing, non-bank financial institution), or
• provide other financial or finance-related services not identified above.
Also complete a separate Schedule G for each activity, as applicable, if you are a director or officer, or are in any other equivalent position with or for, or are a major shareholder or active partner of, an entity that provides one or more of the services in the above list.
Category 5 -- Positions of influence
Instructions: All positions of influence (e.g., medical doctor, leader in a religious organization) are reportable, whether or not you receive compensation for such activities. Guidance: see also section 13.4.3 of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations and the Companion Policy to National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations.
Complete a separate Schedule G for each position of influence that you are in.
Item 11 Previous employment and other activities
On Schedule H, complete your history of employment and other activities for the past 10 years.
Item 12 Resignations and terminations
Have you ever resigned, been terminated or been dismissed for cause by an employer from a position following allegations that you:
1. Violated any statutes, regulations, rules or standards of conduct?
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If "Yes", complete Schedule I, Item 12.1.
2. Failed to appropriately supervise compliance with any statutes, regulations, rules or standards of conduct?
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If "Yes", complete Schedule I, Item 12.2.
3. Committed fraud or the wrongful taking of property, including theft?
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If "Yes", complete Schedule I, Item 12.3.
Item 12 Resignations and terminations
Instructions: Disclose all allegations against you that existed at the time of your resignation or termination. The allegation does not need to be the reason for or cause of your resignation or termination. Sales targets are not considered a standard of conduct of a sponsoring firm.
Have you ever resigned or been terminated from a position or contract when, at the time of your resignation or termination, there existed an allegation that you:
1. Contravened any statutes, regulations, orders of a court or regulatory body, rules or bylaws or failed to meet any standard of conduct of a sponsoring firm or of any professional body?
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Yes |
[ ] |
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[ ] |
If "Yes", complete Schedule I, Item 12.1.
2. Failed to appropriately supervise compliance with any statutes, regulations, orders of a court or regulatory body, rules or bylaws or with any standard of conduct of a sponsoring firm or of any professional body?
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Yes |
[ ] |
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[ ] |
If "Yes", complete Schedule I, Item 12.2.
3. Committed a fraud or the wrongful taking of property, including theft?
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Yes |
[ ] |
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[ ] |
If "Yes", complete Schedule I, Item 12.3.
Item 13 Regulatory disclosure
The questions below relate to any jurisdiction of Canada and any foreign jurisdiction.
1. Securities and derivatives regulation
a) Other than a registration or permitted individual status that has been recorded under this NRD number, are you now, or have you ever been, registered or licensed with any securities regulator or derivatives regulator or both, to trade in or advise on securities or derivatives or both?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item 13.1(a).
b) Have you ever been refused registration or a licence to trade in or advise on securities or derivatives or both?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item 13.1(b).
c) Have you ever been denied the benefit of any exemption from registration provided in any securities or derivatives or both legislation or rules, other than what was disclosed in Item 8.3 of this form?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item 13.1(c).
d) Are you now, or have you ever been subject to any disciplinary proceedings or any order resulting from disciplinary proceedings under any securities legislation or derivatives legislation or both?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item 13.1(d).
2. SRO regulation
a) Other than an approval that has been recorded under this NRD number, are you now, or have you ever been, an approved person of an SRO or similar organization?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item13.2(a).
b) Have you ever been refused approved person status by an SRO or similar organization?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item 13.2(b).
c) Are you now, or have you ever been, subject to any disciplinary proceedings conducted by any SRO or similar organization?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item 13.2(c).
3. Non-securities regulation
Instructions: Only disclose registration or licences to deal with the public in any capacity.
a) Are you now, or have you ever 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 derivatives or both (e.g. insurance, real estate, accountant, lawyer, teacher, medical doctor, mortgage broker or agent)?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item 13.3(a)
b) Have you ever been refused registration or a licence under any legislation relating to your
professionalactivities unrelated to securities or derivatives?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item 13.3(b).
c) Are you now, or have you ever been, a subject of any disciplinary actions conducted under any legislation relating to your
professionalactivities unrelated to securities or derivatives?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule J, Item 13.3(c).
Item 14 Criminal disclosure
The questions below apply to offences committed in any jurisdiction of Canada and any foreign jurisdiction.
You must disclose all offences, including:
• a criminal offence under federal statutes such as the Criminal Code (Canada), Income Tax Act (Canada), the Competition Act (Canada), Immigration and Refugee Protection Act (Canada) and the Controlled Drugs and Substances Act (Canada), even if
• a record suspension has been ordered under the Criminal Records Act (Canada)
• you have been granted an absolute or conditional discharge under the Criminal Code (Canada), and
• a criminal offence, with respect to questions 14.2 and 14.4, of which you or your firm has been found guilty or for which you or your firm have participated in the alternative measures program within the previous three years, even if a record suspension has been ordered under the Criminal Records Act (Canada)
You must disclose all offences, including:
• a criminal offence under the laws of Canada such as the Criminal Code (Canada), the Income Tax Act (Canada), the Competition Act (Canada), the Immigration and Refugee Protection Act (Canada) and the Controlled Drugs and Substances Act (Canada), even if
• a record suspension has been ordered under the Criminal Records Act (Canada), or
• you have been granted an absolute or conditional discharge under the Criminal Code (Canada),
• a criminal offence under the laws of any foreign jurisdiction such as U.S. federal and state criminal offences, and
• a criminal offence, with respect to questions 14.2 and 14.4,
• of which you or any entity when you were a partner, director, officer or major shareholder of that entity has been found guilty, or
• for which you or any entity when you were a partner, director, officer or major shareholder of that entity has participated in the Alternative Measures Program, a diversion program, or any alternative resolution program within the previous 3 years, even if a record suspension has been ordered under the Criminal Records Act (Canada).
You are not required to disclose:
• charges for summary conviction offences that have been stayed for six months or more,
• charges for indictable offences that have been stayed for a year or more,
• offences under the Youth Criminal Justice Act (Canada), and
• speeding or parking violations.
Subject to the exceptions above:
1. Are there any outstanding or stayed charges against you alleging a criminal offence that was committed?
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Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule K, Item 14.1.
2. Have you ever been found guilty, pleaded no contest to, or been granted an absolute or conditional discharge from any criminal offence that was committed?
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Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule K, Item 14.2.
3. To the best of your knowledge, are there any outstanding or stayed charges against any firmentity of which you were, at the time the criminal offence was alleged to have taken place, a partner, director, officer or major shareholder?
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Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule K, Item 14.3.
4. To the best of your knowledge, has any firmentity, when you were a partner, officer, director or major shareholder, ever been found guilty, pleaded no contest to or been granted an absolute or conditional discharge from a criminal offence that was committed?
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Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule K, Item 14.4.
Item 15 Civil disclosure
The questions below relate to any jurisdiction of Canada and any foreign jurisdiction.
1. Are there currently any outstanding civil actions alleging fraud, theft, deceit, misrepresentation or similar misconduct against you or a firm an entity where you are or were a partner, director, officer or major shareholder?
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Yes |
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No |
[ ] |
If "Yes", complete Schedule L, Item 15.1.
2. Have you or a firm an entity where you are or were a partner, director, officer or major shareholder ever been a defendant or respondent in any civil proceeding in which fraud, theft, deceit, misrepresentation or similar misconduct is, or was, successfully established in a judgment?
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Yes |
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No |
[ ] |
If "Yes", complete Schedule L, Item 15.2.
Item 16 Financial disclosure
1. Bankruptcy
Under the laws of any applicable jurisdiction, have you or has any firm when you were a partner, director, officer or major shareholder of that firm:
a) Had a petition in bankruptcy issued or made a voluntary assignment in bankruptcy or any similar proceeding?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule M, Item 16.1(a).
b) Made a proposal under any legislation relating to bankruptcy or insolvency or any similar proceeding?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule M, Item 16.1(b).
c) Been subject to proceedings under any legislation relating to the winding up or dissolution of the firm, or under the Companies' Creditors Arrangement Act (Canada)?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule M, Item 16.1(c).
d) Been subject to or initiated any proceedings, arrangement or compromise with creditors? This includes having a receiver, receiver-manager, administrator or trustee appointed by or at the request of creditors, privately, through court process or by order of a regulatory authority, to hold your assets.
Yes
[ ]
No
[ ]
If "Yes", complete Schedule M, Item 16.1(d).
2. Debt obligations
Over the past 10 years, have you failed to meet a financial obligation of $10,000 or more as it came due or, to the best of your knowledge, has any firm, while you were a partner, director, officer or major shareholder of that firm, failed to meet any financial obligation of $10,000 or more as it came due?
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|
If "Yes", complete Schedule M, Item 16.2.
3. Surety bond or fidelity bond
Have you ever been refused for a surety or fidelity bond?
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|
If "Yes", complete Schedule M, Item 16.3.
4. Garnishments, unsatisfied judgments or directions to pay
Has any federal, provincial, territorial, state authority or court ever issued any of the following against you regarding your indebtedness or, to the best of your knowledge, the indebtedness of a firm where you are or were a partner, director, officer or major shareholder:
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||
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||
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If "Yes", complete Schedule M, Item 16.4.
Item 16 Financial disclosure
1. Bankruptcies, insolvencies, consumer proposals and creditor arrangements
Instructions: You must provide the following information no matter when the event occurred (even if it was longer than 7 years ago).
The information is required to be reported even if you or the entity has been discharged or released from bankruptcy.
Under the laws of any jurisdiction of Canada or any foreign jurisdiction, have any of the following events ever occurred to you or to any entity when you were a partner, director, officer or major shareholder of the entity:
a) had a petition in bankruptcy issued or made a voluntary assignment into bankruptcy or any similar proceeding (no matter when it occurred, even if it was longer than 7 years ago, and even if you or the entity have been discharged or released from bankruptcy)?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule M, Item 16.1(a).
b) a proposal, including a consumer proposal, under any legislation relating to bankruptcy or insolvency or any similar proceeding?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule M, Item 16.1(b).
c) proceedings under any legislation relating to the winding up or dissolution of the entity, or under the Companies' Creditors Arrangement Act (Canada)?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule M, Item 16.1(c).
d) any proceedings, arrangement or compromise with creditors?
Yes
[ ]
No
[ ]
If "Yes", complete Schedule M, Item 16.1(d).
2. Debt obligations
During the past 10 years:
• have you failed to meet a financial obligation of $10,000 or more as it came due, or
• to the best of your knowledge, has any entity, while you were a partner, director, officer or major shareholder of that entity, failed to meet any financial obligation of $10,000 or more as it came due?
|
Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule M, Item 16.2.
3. Surety bond or fidelity bond
Have you ever been refused for a surety or fidelity bond?
|
Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule M, Item 16.3.
4. Garnishments, seizure in the hands of third persons, unsatisfied judgments or directions to pay
Has any governmental or regulatory authority or court, in any jurisdiction, ever issued any of the following
• against you regarding your indebtedness, or
• to the best of your knowledge, against an entity regarding the entity's indebtedness incurred at the time you were a partner, director, officer or major shareholder of the entity:
|
|
Yes |
No |
|
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||
|
Garnishment or seizure in the hands of third persons |
[ ] |
[ ] |
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||
|
Unsatisfied judgment |
[ ] |
[ ] |
|
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||
|
Direction to pay |
[ ] |
[ ] |
If "Yes", complete Schedule M, Item 16.4.
Item 17 Ownership of securities and derivatives firms
Are you now, or have you ever been, a partner or major shareholder of any firm (including your sponsoring firm) whose business is trading in or advising on securities or derivatives or both?
|
Yes |
[ ] |
No |
[ ] |
If "Yes", complete Schedule N.
Item 18 Agent for service
By submitting this form, you certify that in each jurisdiction of Canada where you have appointed an agent for service, you have completed the appointment of agent for service required in that jurisdiction.
Item 19 Submission to jurisdiction
By submitting this form, you agree to be subject to the securities legislation or derivatives legislation or both of each jurisdiction of Canada, and to the by-laws, regulations, rules, rulings and policies (collectively referred to as "rules" in this form) of the SROs to which you have submitted this form. This includes the jurisdiction of any tribunals or any proceedings that relate to your activities as a registrant or a partner, director or officer of a registrant under that securities legislation or derivatives legislation or both or as an Approved Person under SRO rules.
Item 20 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 in the jurisdictions set out in Schedule O to administer and enforce certain provisions of their securities legislation or derivatives legislation or both.
By submitting this form, the individual consents to the collection by the securities regulatory authorities of this personal information, and any police records, records from other government or non-governmental regulators or SROs, credit records and employment records about the individual that the securities regulatory authorities may need to complete their review of the information submitted in this form relating to the individual's continued fitness for registration or approval, if applicable, in accordance with the legal authority of the securities regulatory authorities while the individual is registered with or approved by it. Securities regulatory authorities may contact government and private bodies or agencies, individuals, corporations and other organizations for information about the individual.
If you have any questions about the collection and use of this information, contact the securities regulatory authority in any jurisdiction in which the required information is submitted. See Schedule O for details. In Québec, you can also contact the Commission d'accès à l'information at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca.
SROs
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 rules of the SROs.
By submitting this form, you authorize the SROs to which this form is submitted to collect any information from any source whatsoever. This includes, but is not limited to, personal confidential information about you that is otherwise protected by law such as police, credit, employment, education and proficiency course completion records, and records from other government or non-governmental regulatory authorities, securities commissions, stock exchanges, or other SROs, private bodies, agencies, individuals or corporations, as may be necessary for the SROs to complete their review of your form or continued fitness for registration or approval in accordance with their rules for the duration of the period you remain so registered or approved. You further consent to and authorize the transfer of confidential information between SROs, securities commissions or stock exchanges from whom you now, or may in the future, seek registration or approval, or with which you are currently registered or approved for the purpose of determining fitness or continued fitness for registration or approval or in connection with the performance of an investigation or other exercise of regulatory authority, whether or not you are registered with or approved by them.
By submitting this form, you certify that you understand the rules of the applicable SROs 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 SROs 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 SROs from whom you are seeking 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 form may be revoked, terminated or suspended at any time in accordance with the then applicable rules of the respective SROs. 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 SROs or any approved affiliated company or other affiliate of such member without obtaining the approval of or registration with the SROs, in accordance with their rules.
By submitting this form, you undertake to notify the SROs from whom you are seeking 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 form, without amendment, to other SROs in the event that at some time in the future you seek registration or approval from such other SROs.
You certify that you have discussed the questions in this form, together with this Agreement, with an Officer, Supervisor or Branch Manager of your sponsoring member firm and, to your knowledge and belief, the authorized Officer, Supervisor or Branch Manager was satisfied that you fully understood the questions and the terms of this Agreement. You further certify that your business activities that are subject to securities rules and derivatives rules or both will be limited strictly to those permitted by the category of your registration or approval.
Item 20 Notice and consent for collection and use of personal information
1. Notice of collection and use of personal information
Your personal information is collected by, or on behalf of, each securities regulatory authority and SRO set out in Schedule O. Any of the securities regulatory authorities or SROs set out in Schedule O may contact governmental or regulatory authorities, private bodies or agencies, individuals, corporations, employers, and other organizations, in Canada and in other countries, for information about you.
This personal information is being collected under the authority of the applicable securities legislation, derivatives legislation (including commodity futures legislation) or both of the securities regulatory authorities and under the SRO rules of an SRO set out in Schedule O. The collection, use and disclosure are done in accordance with applicable freedom of information and privacy legislation.
The principal purpose of this collection by the securities regulatory authorities is to administer, enforce, carry out their duties or exercise their powers under their respective securities legislation, derivatives legislation (including commodity futures legislation) or both, and by the SROs to administer and enforce the rules of the SROs.
The information submitted by you in this form with your consent, or collected indirectly with your authorization, may be collected
• at the time of your application,
• at any time during your registration or while you are a permitted individual, or
• at the time the regulator or, in Québec, the securities regulatory authority, or the SRO is informed by your sponsoring firm that you no longer have authority to act on behalf of the sponsoring firm or are not a permitted individual of the sponsoring firm.
If you have any questions about the collection, use and disclosure of this information, contact the securities regulatory authority or SRO in any jurisdiction in which the required information is submitted. See Schedule O for details.
Certain information, such as your name(s) (including aliases, trade names or some past names), your sponsoring firm, and other relevant registration information, will be listed in a publicly available registry of registered individuals and, if applicable, on the Disciplined List.
Certain securities regulatory authorities may provide to or receive from certain entities information under separate provisions of their securities legislation or derivatives legislation (including commodity futures legislation) or both, and SROs may provide or receive information under the rules of the SROs. This consent and notice does not limit the authority, powers, obligations, or rights conferred on any of the securities regulatory authorities by legislation or regulations in effect in their jurisdiction.
2. Consent to collect and use personal information
By submitting this form, you consent to and authorize the collection, directly and indirectly, of personal information by each securities regulatory authority and SRO and to the use of your personal information as set out above.
The personal information that each securities regulatory authority or SRO collects includes the following:
• the personal information provided in this form;
• the personal information provided by your sponsoring firm;
• registration or financial services licensing information;
• law enforcement records, including police records;
• credit records;
• bankruptcy or other insolvency records;
• employment records and information received from an employer;
• records and information received from entities you had or have an independent contractor or agency relationship with;
• personal information available online;
• records from governmental or regulatory authorities, SROs or professional bodies;
• records of, and used in, court proceedings, including probation records.
Item 21 Warning[repealed]
It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.
Item 22 Certification[repealed]
1. Certification -- NRD format
I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm. To the best of my knowledge, the officer, branch manager or supervisor was satisfied that I fully understood the questions. I will limit my activities to those permitted by my category of registration. If the business location specified in this form is a residence, I hereby give my consent for the regulator or, in Québec, the securities regulatory authority to enter that residence for the administration of securities legislation and derivatives legislation, including commodity futures legislation.
I am making this submission as agent for the individual identified in this form. By checking this box, I certify that the individual provided me with all of the information on this form and the certification above.
2. Certification -- Format other than NRD format
Individual
By signing below, I certify to the regulator, or in Québec the securities regulatory authority, in each jurisdiction where I am filing or submitting this form, either directly or through the principal regulator, that:
• I have read this form and understand the questions,
• all of the information provided on this form is true, and complete, and
• if the business location specified in this form is a residence, I hereby give my consent for the regulator or, in Québec, the securities regulatory authority to enter that residence for the administration of securities legislation and derivatives legislation, including commodity futures legislation.
Signature of individual ____________________ Date ____________________
Authorized partner or officer of the firm
By signing below, I certify to the regulator, or in Québec the securities regulatory authority, in each jurisdiction where I am submitting this form, either directly or through the principal regulator, for the individual that:
• the individual identified in this form will be engaged by the sponsoring firm as a registered individual or a permitted individual, and
• I have, or a branch manager, or supervisor, or another officer or partner has, discussed the questions set out in this form with the individual and, to the best of my knowledge, the individual fully understands the questions.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
Schedule A Names (Item 1)
Item 1.2 Other personal names
Name 1:
|
__________ |
__________ |
__________ |
__________ |
|
Last name |
First name |
Second name (N/A [ ]) |
Third name (N/A [ ]) |
Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name or nickname):
______________________________
|
When did you use this name? |
From: |
To: |
|
|
||
|
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
Name 2:
|
__________ |
__________ |
__________ |
__________ |
|
Last name |
First name |
Second name (N/A [ ]) |
Third name (N/A [ ]) |
Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name or nickname):
______________________________
|
When did you use this name? |
From: |
To: |
|
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||
|
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
Name 3:
|
__________ |
__________ |
__________ |
__________ |
|
Last name |
First name |
Second name (N/A [ ]) |
Third name (N/A [ ]) |
Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name or nickname):
______________________________
|
When did you use this name? |
From: |
To: |
|
|
||
|
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
Item 1.3 Use of other names
Name 1:
Name: ____________________
Provide the reasons for the use of this other name (for example, trade name or team name): __________________________
If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?
|
Yes |
[ ] |
No |
[ ] |
N/A |
[ ] |
|
When did you use this name? |
From: |
To: |
|
|
||
|
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
Name 2:
Name: ____________________
Provide the reasons for the use of this other name (for example, trade name or team name): ____________________
If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?
|
Yes |
[ ] |
No |
[ ] |
N/A |
[ ] |
|
When did you use this name? |
From: |
To: |
|
|
||
|
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
Name 3:
Name: ____________________
Provide the reasons for the use of this other name (for example, trade name or team name): __________________________
If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?
|
Yes |
[ ] |
No |
[ ] |
N/A |
[ ] |
|
When did you use this name? |
From: |
To: |
|
|
||
|
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
Schedule B Residential address (Item 2)
Item 2.1 Current and previous residential addresses
If you have lived at your current address for less than 10 years, list all previous addresses for the past 10 years.
You do not have to include a postal code or ZIP code, or a telephone number for any previous address.
Address 1:
Residential address: ____________________ (number, street, city, province, territory or state, country)
|
When did you use this name? |
From: |
To: |
|
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||
|
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
Address 2:
Residential address: ____________________ (number, street, city, province, territory or state, country)
|
When did you use this name? |
From: |
To: |
|
|
||
|
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
Address 3:
Residential address: ____________________ (number, street, city, province, territory or state, country)
|
When did you use this name? |
From: |
To: |
|
|
||
|
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
Schedule C Individual categories (Item 6)
Check each category for which you are seeking registration, approval or review as a permitted individual.
- - - - - - - - - - - - - - - - - - - -
Categories common to all jurisdictions under securities legislation
Firm categories [Format other than NRD format only]
[ ] Investment Dealer
[ ] Mutual Fund Dealer
[ ] Scholarship Plan Dealer
[ ] Exempt Market Dealer
[ ] Restricted Dealer
[ ] Portfolio Manager
[ ] Restricted Portfolio Manager
[ ] Investment Fund Manager
Individual categories and permitted activities
[ ] Dealing Representative
[ ] Advising Representative
[ ] Associate Advising Representative
[ ] Ultimate Designated Person
[ ] Chief Compliance Officer
[ ] Permitted Individual
[ ] Officer -- Specify title:
[ ] Director
[ ] Partner
[ ] Shareholder
[ ] Branch Manager (MFDA members only)
[ ] IIROC approval only
IIROC
Approval categories
[ ] Executive
[ ] Director (Industry)
[ ] Director (Non-Industry)
[ ] Supervisor
[ ] Investor
[ ] Registered Representative
[ ] Investment Representative
[ ] Trader[ ] Executive
[ ] Director (Industry)
[ ] Director (Non-Industry)
[ ] Supervisor
[ ] Investor
[ ] Registered Representative
[ ] Investment Representative
[ ] Portfolio Manager
[ ] Associate Portfolio Manager
[ ] Trader
Additional approval categories
[ ] Chief Compliance Officer
[ ] Chief Financial Officer
[ ] Ultimate Designated Person
Products
[ ] Non-Trading
[ ] Securities
[ ] Options
[ ] Futures Contracts and Futures Contract Options
[ ] Mutual Funds only
Customer type
[ ] Retail
[ ] Institutional
[ ] Not Applicable
Portfolio management
[ ] Portfolio Management
Categories under local commodity futures and derivatives legislation
Ontario
Firm categories
[ ] Commodity Trading Adviser
[ ] Commodity Trading Counsel
[ ] Commodity Trading Manager
[ ] Futures Commission Merchant
Individual categories and permitted activities
[ ] Advising Representative
[ ] Salesperson
[ ] Branch Manager
[ ] Officer -- Specify title:
[ ] Director
[ ] Partner
[ ] Shareholder
[ ] IIROC approval only
Manitoba
Firm categories
[ ] Dealer (Merchant)
[ ] Dealer (Futures Commission Merchant)
[ ] Dealer (Floor Broker)
[ ] Adviser
[ ] Local
Individual categories and permitted activities
[ ] Floor Broker
[ ] Salesperson
[ ] Branch Manager
[ ] Adviser
[ ] Officer -- Specify title:
[ ] Director
[ ] Partner
[ ] Futures Contracts Portfolio Manager
[ ] Associate Futures Contracts Portfolio Manager
[ ] IIROC approval only
[ ] Local
Québec
Firm categories
[ ] Derivatives Dealer
[ ] Derivatives Portfolio Manager
Individual categories and permitted activities
[ ] Derivatives Dealing Representative
[ ] Derivatives Advising Representative
[ ] Derivatives Associate Advising Representative
Schedule D Address and agent for service (Item 7)
Item 7.1 Address for service
You must have one address for service in each province or territory in which you are now, or are seeking to become, a registered individual or permitted individual. A post office box is not an acceptable address for service.
Address for service: ____________________ (number, street, city, province or territory, postal code)
Telephone number: (___) ____________________
Fax number: (___) ____________________
Business e-mail address: ____________________
Item 7.2 Agent for service
If you have appointed an agent for service, provide the following information about the agent. The address for service provided above must be the address of the agent named below.
Name of agent for service: ____________________
(if applicable)
Contact person:____________________ Last name, First name
Schedule E Proficiency (Item 8)
Item 8.1 Course, examination or designation information and other education
Instructions: Please see Division 2 [Education and experience requirements] in Part 3 [Registration requirements -- individuals] of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations for the education and experience requirements for the categories that you are seeking to be registered in or the relevant SRO rules for the SRO approval categories.
Below, state each course, examination and designation that:
• is required for the registration categories or SRO approval categories you are applying for, and
• you have successfully completed.
*For IIROC applicants only -- If applicable, please indicate the date of any exemption granted for any course, examination, designation or other education required for approval.
|
Course, examination, designation or other education |
Date completed (YYYY/MM/DD) |
Date exempted* (YYYY/MM/DD) |
Regulator / securities regulatory authority granting the exemption* |
|
|
|||
|
__________ |
__________ |
__________ |
__________ |
If you have listed the CFA Charter in Item 8.1, please indicate by checking "Yes" below if you are a current member of the CFA Institute permitted to use this charter.
|
Yes |
[ ] |
No |
[ ] |
If "No", please explain why you no longer hold this designation:
______________________________
______________________________
______________________________
If you have listed the Canadian Investment Manager Designation in Item 8.1, please indicate by checking "Yes" below if you are currently permitted to use this designation.
|
Yes |
[ ] |
No |
[ ] |
If "No", please explain why you no longer hold this designation:
______________________________
______________________________
______________________________
Schedule F Proficiency (Items 8.3 and 8.4)
Item 8.3 Exemption refusal
Complete the following for each exemption that was refused.
1. Which securities regulator, derivatives regulator or SRO refused to grant the exemption?
______________________________
State the name of the course, examination, designation or experience requirement:
______________________________
State the reason given for not being granted the exemption:
______________________________
Date exemption refused: ____________________ (YYYY/MM/DD)
2. Which securities regulator, derivatives regulator or SRO refused to grant the exemption?
______________________________
State the name of the course, examination, designation or experience requirement:
______________________________
State the reason given for not being granted the exemption:
______________________________
Date exemption refused: ____________________ (YYYY/MM/DD)
3. Which securities regulator, derivatives regulator or SRO refused to grant the exemption?
______________________________
State the name of the course, examination, designation or experience requirement:
______________________________
State the reason given for not being granted the exemption:
______________________________
Date exemption refused: ____________________ (YYYY/MM/DD)
Item 8.4 Relevant securities industry experience
Describe your responsibilities in areas relating to the category you are applying for, including the title(s) you have held, as well as start and end dates:
______________________________
______________________________
______________________________
What is the percentage of your time devoted to these activities?
_____ %
Indicate the continuing education activities in which you have participated during the last 36 months and that are relevant to the category of registration you are applying for:
______________________________
______________________________
______________________________
Item 8.4 Relevant securities experience
Instructions:
• Some registration categories require a specified amount of experience to have been obtained within specified timeframes. Please see National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations or the relevant SRO rules for more information.
• If you are applying to be an advising representative or an associate advising representative, or with IIROC as a portfolio manager, associate portfolio manager, or supervisor designated to be responsible for the supervision of managed accounts, provide details of the activities you performed for each position in which you gained is relevant investment management experience. Such details may include the level of responsibility; value of accounts under direct supervision; number of years of experience in performing securities research and analysis for the purpose of portfolio securities selection, portfolio construction and analysis; type of experience in performing client relationship management; number of years of experience collecting know-your-client information; or number of years of experience conducting suitability assessments.
• If you are applying as an advising representative limited to client relationship management, indicate this by including the following statement: "Individual seeking registration as CRM AR".
• For all other categories, provide details of activities that you performed for each position in which you gained relevant securities industry experience.
1. If you are applying
• to be an advising representative or an associate advising representative of a portfolio manager, describe the relevant investment management experience that you have gained, or
• for any other category, describe the relevant securities industry experience that you have gained.
For each position in which you gained relevant experience, provide the following information:
(a) the name of the firm or entity with which you gained this experience;
(b) your title;
(c) the start and end dates of this position;
(d) the details of the activities you performed that are relevant for the category of registration that you are applying for;
(e) the percentage of your time in this position that was spent on activities relating to the experience.
______________________________
______________________________
______________________________
2. Indicate the continuing education activities in which you have participated during the last 36 months and that are relevant to the category of registration you are applying for:
______________________________
______________________________
______________________________
Schedule G Current employment, other business activities, officer positions held and directorships (Item 10)
Complete a separate Schedule G for each of your current business and employment activities, including employment and business activities with your sponsoring firm and any employment and business activities outside your sponsoring firm. Also include all officer or director positions and any other equivalent positions held, as well as positions of influence. The information must be provided
• whether or not you receive compensation for such services, and
• whether or not any such position is business related.
1. Start date ____________________ (YYYY/MM/DD)
2. Firm information
[ ] Check here if this activity is employment with your sponsoring firm.
If the activity is with your sponsoring firm, you are not required to indicate the firm name and address information below:
Name of business or employer: ____________________
Address of business or employer: ____________________ (number, street, city, province, territory or state, country)
Name and title of your immediate supervisor: ____________________
3. Description of duties
Describe all employment and business activities related to this employer. Include the nature of the business and your duties, title or relationship with the business. If you are seeking registration that requires specific experience, include details such as level of responsibility, value of accounts under direct supervision, number of years of experience, and percentage of time spent on each activity.
______________________________
4. Number of work hours per week
How many hours per week do you devote to this business or employment?_____________
If this activity is employment with your sponsoring firm and you work less than 30 hours per week, explain why.
______________________________
5. Conflicts of interest
If you have more than one employer or are engaged in business related activities:
A. Disclose any potential for confusion by clients and any potential for conflicts of interest arising from your multiple employment or business related activities or proposed business related activities.
______________________________
______________________________
______________________________
B. Indicate whether or not any of your employers or organizations where you engage in business related activities are listed on an exchange.
______________________________
C. Confirm whether the firm has procedures for minimizing potential conflicts of interest and if so, confirm that you are aware of these procedures.
______________________________
______________________________
______________________________
D. State the name of the person at your sponsoring firm who has reviewed and approved your multiple employment or business related activities or proposed business related activities.
______________________________
E. If you do not perceive any conflicts of interest arising from this employment, explain why.
______________________________
______________________________
______________________________
Schedule G Reportable activities (Item 10)
1. Start date ____________________ (YYYY/MM/DD)
2. Sponsoring firm or other entity information
[ ] Check here if the reportable activity is with your sponsoring firm.
If the reportable activity is with your sponsoring firm, you are not required to indicate the firm's name and address but are required to provide the name and title of your immediate supervisor. For all other types of reportable activity, enter all of the information below:
Name of business or employer: ____________________
Address of business or employer: ____________________ (number, street, city, province, territory or state, country)
Name and title of your immediate supervisor: ____________________
3. Description of the reportable activity and your roles and responsibilities
Instructions: If you are completing this schedule in relation to your activities with your sponsoring firm, for (e) below, provide the title(s) you will use once registered, and if you are already registered, provide the title(s) you use as of the date of this filing.
(a) Describe the entity that you carry on the activity with or for, including the nature of the entity's business.
(b) Is the entity listed on an exchange?
(c) Describe your relationship with the entity.
(d) Describe all of your roles and responsibilities relating to the activity.
______________________________
(e) Provide all business title(s) and professional designation(s) you use for the activity.
______________________________
4. Number of work hours per week
How many hours per week do you spend on this activity? _____________
5. Conflicts of interest
Instructions: Complete this section if you have a reportable activity outside your sponsoring firm. Do not complete this section if your reportable activity is solely with your sponsoring firm.
Take into consideration existing and reasonably foreseeable material conflicts of interest and existing and potential client confusion.
(a) Does the activity give rise to any material conflicts of interest between the client and the sponsoring firm or you? Does the activity give rise to client confusion? If no conflicts of interest or client confusion are expected, explain why.
______________________________
______________________________
______________________________
(b) Describe (i) the material conflicts of interest, and (ii) how these conflicts will be addressed in the best interest of the client.
______________________________
(c) Describe (i) the client confusion, and (ii) how the client confusion will be addressed.
______________________________
______________________________
______________________________
(d) Does your sponsoring firm and the entity have procedures for identifying and addressing material conflicts of interest? If so, confirm you are complying with both sets of procedures.
______________________________
(e) State the name and title of the individual at your sponsoring firm who has reviewed and approved the activity.
______________________________
______________________________
______________________________
Schedule H Previous employment and other activities (Item 11)
Provide the following information for each of your employment and other activities in the past 10 years. Account for all of your time, including full-time and part-time employment, self-employment or military service. Include your status for each, such as unemployed, full-time student, or other similar statuses. Do not include short-term employment of four months or less while a student, unless it was in the securities, derivatives or financial industry.
In addition to the information required in the paragraph above, if you were employed or had business activities in the securities or derivatives industry or both during and before the 10-year period, disclose all your securities and derivatives or both employment or business activities (both before and during the 10-year period).
[ ] Unemployed
[ ] Full-time student
[ ] Employed or self-employed
From: ____________________ (YYYY/MM)
To: ____________________ (YYYY/MM)
Complete the following only if you are, or were, employed or self-employed during this period.
______________________________
Name of business or employer:
____________________
Address of business or employer:
____________________ (number, street, city, province, territory or state, country)
Name and title of immediate supervisor, if applicable:
______________________________
Describe the firm's business, your position, duties and your relationship to the firm. If you are seeking registration in a category of registration that requires specific experience, include details of that experience. Examples include level of responsibility, value of accounts under direct supervision, number of years of that experience and research experience, and percentage of time spent on each activity.
Reason why you left the firm:
______________________________
______________________________
______________________________
Schedule I Resignations and terminations (Item 12)
Item 12.1
For each allegation of violation of any statutes, regulations, rules or internal/external standards of conduct, state below (1) the name of the firm from which you resigned, were terminated or dismissed for cause, (2) whether you resigned, were terminated or dismissed for cause, (3) the date you resigned, were terminated or dismissed for cause, and (4) the circumstances relating to your resignation, termination or dismissal for cause.
______________________________
Item 12.2
For each allegation of failure to supervise compliance with any statutes, regulations, rules or standards of conduct, state below, (1) the name of the firm from which you resigned, were terminated or dismissed for cause, (2) whether you resigned, were terminated or dismissed for cause, (3) the date you resigned, were terminated or dismissed for cause, and (4) the circumstances relating to your resignation, termination or dismissal for cause.
______________________________
Item 12.3
For each allegation of fraud or the wrongful taking of property, including theft, state below (1) the name of the firm from which you resigned, were terminated or dismissed for cause, (2) whether you resigned, were terminated or dismissed for cause, (3) the date you resigned, were terminated or dismissed for cause, and (4) the circumstances relating to your resignation, termination or dismissal for cause.
______________________________
Schedule I Resignations and terminations (Item 12)
Item 12.1
For each allegation of contravention of any statute, regulation, order of a court or regulatory body, rule or bylaw or failure to meet any standard of conduct of a sponsoring firm or of any professional body, state below (1) the name of the firm from which you resigned or were terminated, (2) whether you resigned or were terminated, (3) the date you ceased to carry on duties, (4) the circumstances relating to your resignation or termination, (5) details of the allegation (regardless of whether the allegation caused or contributed to your resignation or termination), including the statutes, regulations, orders, rules or bylaws allegedly contravened or standards of conduct allegedly not met, (6) details of how the allegation was addressed, and (7) any details of the resignation, termination, or allegation relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
Item 12.2
For each allegation of failure to supervise compliance with any statute, regulation, order of a court or regulatory body, rule or bylaw or with any standard of conduct of a sponsoring firm or of any professional body, state below, (1) the name of the firm from which you resigned or were terminated, (2) whether you resigned or were terminated, (3) the date you ceased to carry on duties, (4) the circumstances relating to your resignation or termination, (5) details of the allegation of failure to supervise (regardless of whether the allegation caused or contributed to your resignation or termination), (6) details of how the allegation was addressed, and (7) any details of the resignation, termination, or allegation relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
Item 12.3
For each allegation that you committed a fraud or the wrongful taking of property, including theft, state below (1) the name of the firm from which you resigned or were terminated, (2) whether you resigned or were terminated, (3) the date you ceased to carry on duties, (4) the circumstances relating to your resignation or termination, (5) details of the allegation (regardless of whether the allegation caused or contributed to your resignation or termination), (6) details of how the allegation was addressed, and (7) any details of the resignation, termination, or allegation relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
Schedule J Regulatory disclosure (Item 13)
Item 13.1 Securities and derivatives regulation
a) For each registration or licence, state below (1) the name of the firm, (2) the securities or derivatives regulator with which you are, or were, registered or licensed, (3) the type or category of registration or licence, and (4) the period that you held the registration or licence.
______________________________
b) For each registration or licence refused, state below (1) the name of the firm, (2) the securities or derivatives regulator 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.
______________________________
c) For each exemption from registration denied or licence refused, other than what was disclosed in Item 8.3 of this form, state below (1) the party that was refused the exemption from registration or licence, (2) the securities or derivatives regulator that refused the exemption from registration or licence, (3) the type or category or registration or licence refused, (4) the date of the refusal, and (5) the reasons for the refusal.
______________________________
d) For each order or disciplinary proceeding, state below (1) the name of the firm, (2) the securities or derivatives regulator that issued the order or is conducting or conducted 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), (6) whether you are or were a partner, director, officer or major shareholder of the firm and named individually in the order or disciplinary proceeding, and (7) any other relevant details.
______________________________
Item 13.2 SRO regulation
a) For each approval, state below (1) the name of the firm, (2) the SRO with which you are or were an approved person, (3) the categories of approval, and (4) the period that you held the approval.
______________________________
b) For each approval refused, state below (1) the name of the firm, (2) the SRO that refused the approval, (3) the category of approval refused, (4) the date of the refusal, and (5) the reasons for the refusal.
______________________________
c) For each order or disciplinary proceeding, state below (1) the name of the firm, (2) the SRO 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), (6) whether you are or were a partner, director, officer or major shareholder of the firm and named individually in the order or disciplinary proceeding, and (7) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.c) For each order or disciplinary proceeding, state below (1) the name of the firm, (2) the SRO 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, (6) whether you are or were a partner, director, officer or major shareholder of the firm and named individually in the order or disciplinary proceeding, and (7) any details of the order or disciplinary proceeding relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
Item 13.3 Non-securities regulation
a) For each registration or licence, state below (1) the party who is, or was, registered or licensed (if insurance licensed, also indicate the name of the insurance agency), (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 period that the party held the registration or licence.
______________________________
b) For each registration or licence refused, state below (1) the party that was refused registration or licensing (if insurance licensed, also indicate the name of the insurance agency), (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 (if insurance licensed, indicate the name of the insurance agency), (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), (6) whether you are or were a partner, director, officer or major shareholder of the firm and named individually in the order or disciplinary proceeding and (7) any other information that you think is relevant or that the regulatory authority may request.
______________________________a) For each registration or licence, state below (1) the party who is, or was, registered or licensed, (2) if applicable, the employer or entity for whom you performed the registerable or licensable activity, (3) the period that the party held the registration or licence, (4) the type or category of registration or licence, (5) with which regulatory authority, or under what legislation, the party is, or was, registered or licensed, and (6) the licence number.
______________________________
b) For each registration or licence refused, state below (1) the party that was refused registration or licensing, (2) if applicable, the employer or entity for whom you performed the registerable or licensable activity, (3) with which regulatory authority, or under what legislation, the registration or licence was refused, (4) the type or category of registration or licence refused, (5) the date of the refusal, and (6) 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, (6) whether you are or were a partner, director, officer or major shareholder of the entity and named individually in the order or disciplinary proceeding, and (7) any details of the order or disciplinary proceeding relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
Schedule K Criminal disclosure (Item 14)
Item 14.1
For each charge, state below (1) the type of charge, (2) the date of the charge, (3) any trial or appeal dates, and (4) the court location.
______________________________
Item 14.2
For each finding of guilty, pleading no contest to, or granting of an absolute or conditional discharge from a criminal offence, state below (1) the offence, (2) the date found guilty, and (3) the disposition (any penalty or fine and the date any fine was paid).
______________________________
Item 14.3
For each charge, state below (1) the name of the firmentity, (2) the type of charge, (3) the date of the charge, (4) any trial or appeal dates, and (5) the court location.
______________________________
Item 14.4
For each finding of guilty, pleading no contest to, or granting of an absolute or conditional discharge from a criminal offence, state below (1) the name of the firmentity, (2) the offence, (3) the date of the conviction, and (4) the disposition (any penalty or fine and the date any fine was paid).
______________________________
Schedule L Civil disclosure (Item 15)
Item 15.1
For each outstanding civil proceeding, state below (1) the dates the statement of claim and statement of defence were issued, (2) the name of the plaintiff(s) in the proceedingthe name of each plaintiff in the proceeding , (3) whether the proceeding is pending or on appeal, (4) whether the proceeding was against a firman entity where you are, or were, a partner, director, officer or major shareholder and whether you have been named individually in the allegations, and (5) the jurisdiction where the action is being pursued.
______________________________
Item 15.2
For each civil proceeding, state below (1) the dates the statement of claim and statement of defence were issued, (2) each plaintiff in the proceedingthe name of each plaintiff in the proceeding, (3) the jurisdiction where the action was pursued, (4) whether the proceeding was about a firman entity where you are, or were, a partner, director, officer or major shareholder and whether you have been named individually in the allegations, and (5) a summary of any disposition or any settlement over $10,000. You must disclose any actions settled without admission of liability.
______________________________
Schedule M Financial disclosure (Item 16)
Item 16.1 Bankruptcy
(a) For each event, state below (1) the date of the petition or voluntary assignment, (2) the person or firm about whom this disclosure is being made, (3) any amounts currently owing, (4) the creditors, (5) the status of the matter, (6) a summary of any disposition or settlement, (7) date of discharge or release, if applicable, and (8) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.
______________________________
(b) For each event, state below (1) the date of the proposal, (2) the person or firm about whom this disclosure is being made, (3) any amounts currently owing, (4) the creditors, (5) the status of the matter, (6) a summary of any disposition or settlement, and (7) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.
______________________________
(c) For each event, state below (1) the date of the proceeding, (2) the person or firm about whom this disclosure is being made, (3) any amounts currently owing, (4) the creditors, (5) the status of the matter, (6) a summary of any disposition or settlement, and (7) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.
______________________________
(d) For each proceeding, arrangement or compromise with creditors, state below (1) the date of proceeding, (2) the person or firm about whom this disclosure is being made, (3) any amounts currently owing, (4) the creditors, (5) the status of the matter, (6) a summary of any disposition or settlement, and (7) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.
______________________________
Item 16.2 Debt obligation
For each event, state below (1) the person or firm that failed to meet its financial obligation, (2) the amount that was owing at the time the person or firm failed to meet its financial obligation, (3) the person or firm 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 the regulator or, in Québec, the securities regulatory authority may request, including why the obligation has not been met/satisfied.
______________________________
Item 16.3 Surety bond or fidelity bond
For each bond refused, state 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.
______________________________
Item 16.4 Garnishments, unsatisfied judgments or directions to pay
For each garnishment, unsatisfied judgment or direction to pay regarding your indebtedness, indicate below (1) the amount that was owing at the time the garnishment, judgment or direction to pay was rendered, (2) the person or firm 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) the percentage of earnings to be garnished or the amount to be paid, (5) any amounts currently owing, and (6) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.
Schedule M Financial disclosure (Item 16)
Item 16.1 Bankruptcies, insolvencies, consumer proposals and creditor arrangements
Instructions: Proposals includes consumer proposals.
(a) For each event, state below (1) the date of the petition or voluntary assignment into bankruptcy, or a similar proceeding, (2) the person or entity about whom this disclosure is being made, (3) any amounts currently owing, (4) the creditors, (5) the status of the matter, (6) a summary of any disposition or settlement, (7) the date of discharge or release, if applicable, and (8) any details of the petition or voluntary assignment into bankruptcy or similar proceeding relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
(b) For each event, state below (1) the date of the proposal, (2) the person or firm about whom this disclosure is being made, (3) any amounts currently owing, (4) the creditors, (5) the status of the matter, (6) a summary of any disposition or settlement, and (7) any details of the proposal relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
(c) For each event, state below (1) the date of the proceeding, (2) the person or entity about whom this disclosure is being made, (3) any amounts currently owing, (4) the creditors, (5) the status of the matter, (6) a summary of any disposition or settlement, and (7) any details of the relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
(d) For each proceeding, arrangement or compromise with creditors, state below (1) the date of the proceeding, arrangement or compromise, (2) the person or entity about whom this disclosure is being made, (3) any amounts currently owing, (4) the creditors, (5) the status of the matter, (6) a summary of any disposition or settlement, and (7) any details of the proceeding, arrangement or compromise relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
Item 16.2 Debt obligation
For each event, state below (1) the person or entity that failed to meet its financial obligation, (2) the amount that was owing at the time the person or entity failed to meet its financial obligation, (3) the person or entity 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 details of the debt obligation relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable, including why the obligation has not been met or satisfied.
______________________________
Item 16.3 Surety bond or fidelity bond
For each bond refused, state 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.
______________________________
Item 16.4 Garnishments, seizure in the hands of third persons, unsatisfied judgments or directions to pay
For each garnishment, seizure in the hands of third persons, unsatisfied judgment or direction to pay regarding your indebtedness or the indebtedness of an entity incurred at the time you were a partner, director, officer or major shareholder, indicate below (1) the amount that was owing at the time the garnishment, seizure in the hands of third persons, judgment or direction to pay was rendered, (2) the person or entity 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) why the indebtedness has not been met or satisfied, (5) the percentage of earnings to be garnished or seized in the hands of third persons or the amount to be paid, (6) any amounts currently owing, and (7) any details of the garnishment, seizure in the hands of third persons, unsatisfied judgment or direction to pay relevant to the determination of your suitability for registration or whether your registration is otherwise objectionable.
______________________________
Schedule N Ownership of securities and derivatives firms (Item 17)
Name of firm (whose business is trading in or advising on securities or derivatives, or both):
______________________________
What is your relationship to the firm? Partner [ ] Major shareholder [ ]
What is the period of this relationship?
From: To: (if applicable)
__________ (YYYY/MM) __________ (YYYY/MM)
Provide the following information:
a) State the number, value, class and percentage of securities, or the amount of partnership interest you own or propose to acquire when you are registered or approved as a result of the review of this form. If acquiring shares when you are so approved or registered, state the source (for example, treasury shares, or if upon transfer, state name of transferor).
______________________________
b) State the market value (approximate, if necessary) of any subordinated debentures or bonds of the firm to be held by you or any other subordinated loan to be made by you to the firm:
______________________________
c) If another person or firm has provided you with funds to invest in the firm, provide the name of the person or firm and state the relationship between you and that person or firm:
______________________________
d) Are the funds to be invested (or proposed to be invested) guaranteed directly or indirectly by any person or firm?
Yes
[ ]
No
[ ]
If "Yes", provide the name of the person or firm and state the relationship between you and that person or firm:
______________________________
e) Have you directly or indirectly given up any rights relating to these securities or this partnership interest, or do you, when you are registered or approved as a result of the review of this form, intend to give up any of these rights (including by hypothecation, pledging or depositing as collateral the securities or partnership interest with any firm or person)?
Yes
[ ]
No
[ ]
If "Yes", provide the name of the person or firm, state the relationship between you and that person or firm and describe the rights that have been or will be given up:
______________________________c) If another person or entity has provided you with funds to invest in the firm, provide the name of the person or entity and state the relationship between you and that person or entity:
______________________________
d) Is the payment of the funds to be invested (or proposed to be invested) guaranteed directly or indirectly by any person or entity?
Yes
[ ]
No
[ ]
If "Yes", provide the name of the person or entity and state the relationship between you and that person or entity:
______________________________
e) Have you directly or indirectly given up any rights relating to these securities or this partnership interest, or do you, when you are registered or approved as a result of the review of this form, intend to give up any of these rights (including by hypothecation, pledging or depositing as collateral the securities or partnership interest with any entity or person)?
Yes
[ ]
No
[ ]
If "Yes", provide the name of the person or entity, state the relationship between you and that person or entity and describe the rights that have been or will be given up:
______________________________
f) Is a person other than you the beneficial owner of the shares, bonds, debentures, partnership units or notes held by you?
Yes
[ ]
No
[ ]
If "Yes", complete (g), (h) and (i).
g) Name of beneficial owner:
__________
__________
__________
__________
Last name
First name
Second name (N/A [ ])
Third name (N/A [ ])
h) Residential address:
____________________ (number, street, city, province, territory or state, country, postal code)
i) Occupation:
______________________________
Schedule O Contact information for Notice of notice and consent for collection and use of personal information
|
Alberta |
Nunavut |
|
Alberta Securities Commission, |
Government of Nunavut |
|
Suite 600, 250-5th St. SW |
Department of Justice |
|
Calgary, AB T2P 0R4 |
P.O. Box 1000 Station 570 |
|
Attention: Information Officer |
Iqaluit, NU X0A 0H0 |
|
Telephone: (403) 297-6454 |
Attention: Deputy Registrar of Securities |
|
Telephone: (867) 975-6590 |
|
|
|
|
|
British Columbia |
Ontario |
|
British Columbia Securities Commission |
Ontario Securities Commission |
|
P.O. Box 10142, Pacific Centre |
22nd Floor |
|
701 West Georgia Street |
20 Queen Street West |
|
Vancouver, BC V7Y 1L2 |
Toronto, ON M5H 3S8 |
|
Attention: |
Attention: Compliance and Registrant Regulation |
|
Telephone: (604) 899-6500 or (800) 373-6393 (in Canada) |
Telephone: (416) 593-8314 |
|
E-mail: [email protected] |
E-mail: [email protected] |
|
|
|
|
Manitoba |
Prince Edward Island |
|
The Manitoba Securities Commission |
Securities Office |
|
500 -- 400 St. Mary Avenue |
Department of Community Affairs and Attorney General |
|
Winnipeg, MB R3C 4K5 |
P.O. Box 2000 |
|
Attention: Director of Registrations |
Charlottetown, PE C1A 7N8 |
|
Telephone: (204) 945-2548 |
Attention: Deputy Registrar of Securities |
|
Fax (204) 945-0330 |
Telephone: (902) 368-6288 |
|
|
|
|
New Brunswick |
Québec |
|
Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick |
Autorité des marchés financiers |
|
Suite 300, 85 Charlotte Street |
800, square Victoria, 22e étage |
|
Saint John, NB E2L 2J2 |
C.P. 246, tour de la Bourse |
|
Attention: Director of Securities |
Montréal (Québec) H4Z 1G3 |
|
Telephone: (506) 658-3060 |
Attention: Responsable de l'accès à l'information |
|
Telephone: (514) 395-0337 or (877) 525-0337 |
|
|
|
|
|
Newfoundland and Labrador |
Saskatchewan |
|
Superintendent of Securities, Service NL |
Financial and Consumer Affairs Authority of Saskatchewan |
|
Government of Newfoundland and Labrador |
Suite 601, 1919 Saskatchewan Drive |
|
P.O. Box 8700 |
Regina, SK S4P 4H2 |
|
2nd Floor, West Block |
Attention: |
|
Confederation Building |
Telephone: (306) 787-5871 |
|
St. John's, NL A1B 4J6 |
E-mail: [email protected] |
|
Attention: Manager of Registrations |
|
|
Telephone: (709) 729-5661 |
|
|
|
|
|
Nova Scotia |
Yukon |
|
Nova Scotia Securities Commission |
Government of Yukon |
|
Suite 400, 5251 Duke Street |
Office of the Yukon Superintendent of Securities |
|
Halifax, NS B3J 1P3 |
Department of Community Services |
|
Attention: |
P.O. Box 2703 C-6 |
|
Telephone: (902) 424-7768 |
Whitehorse, YT Y1A 2C6 |
|
Attention: Superintendent of Securities |
|
|
Telephone: |
|
|
|
|
|
Northwest Territories |
Self-regulatory organization |
|
Government of the Northwest Territories |
Investment Industry Regulatory Organization of Canada |
|
Department of Justice |
121 King Street West, Suite 2000 |
|
1st Floor Stuart M. Hodgson Building |
Toronto, Ontario M5H 3T9 |
|
5009 -- 49th Street |
Attention: Privacy Officer |
|
Yellowknife, NWT X1A 2L9 |
Telephone: (416) 364-6133 |
|
Attention: |
E-mail: [email protected] |
|
Telephone: (867) 920-8984 |
|
FORM 33-109F5 CHANGE OF REGISTRATION INFORMATION (sections 3.1 and 4.1)
WARNING -- It is an offence to knowingly give false or misleading information to the regulator or the securities regulatory authority.
CERTIFICATION
1. Form 33- 109F4: Use the following certification when making changes to Form 33-109F4
Individual
I, the individual, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where I am submitting this form and to any applicable self-regulatory organization (SRO) that
• I have read this form,
• I have read Form 33-109F4 and understand its questions and, for greater certainty, if the business location is a residence, the notice in Item 9,
• I have discussed Form 33-109F4 with a branch manager, supervisor, officer or partner of my sponsoring firm and that to the best of my knowledge, the branch manager, supervisor, officer or partner is satisfied that I understand all matters within Form 33-109F4, including the questions,
• to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete, including information required to be disclosed by Form 33-109F4 that I am not changing with this form, and
• if applicable, I will limit my activities to those allowed by my category of registration and any SRO approval.
I consent to and authorize the collection, directly and indirectly, of personal information by each regulator, securities regulatory authority and SRO and to the use of my personal information as set out in Item 3.
Firm
I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm is submitting this form and to any applicable SRO that
• the individual identified in this form will be engaged by the sponsoring firm as a registered individual or a permitted individual, and
• I have, or a branch manager, supervisor, officer or partner has, discussed Form 33-109F4 with the individual. To the best of my knowledge, the individual understands all matters within Form 33-109F4, including the questions.
NRD format:
[ ] I, the authorized firm representative, am making this submission under authority delegated by the firm and the individual identified in this form. By checking this box, I certify that
(a) the firm provided me with all of the information on this form and makes the firm certification above,
(b) the individual provided the firm with all of the information on this form and makes the individual certification above, and
(c) the individual provided the above consent and authorization for the collection and use of the individual's personal information.
Non-NRD format:
Individual
By signing below, I, the individual, make the above individual certification and provide my consent and authorization for the collection, directly and indirectly, and use of my personal information.
Signature of individual ____________________
Date signed ____________________ (YYYY/MM/DD)
Firm
By signing below, I, on behalf of the firm, make the firm certification above.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
2. Form 33- 109F6: Use the following certification when making changes to Form 33- 109F6
By signing below, I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm submitting this form and to any applicable SRO that
• I have read this form and understand all matters within this form, including the questions, and to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
GENERAL INSTRUCTIONS
Complete and submit this form to notify the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-regulatory organization (SRO) of changes to information in the following forms:
• Form 33-109F6, except for the changes set out in section 3.1 of National Instrument 33-109, or
• Form 33-109F4.
How to submit this form
To report changes to information in a Form 33-109F4, submit this form at the National Registration Database website in NRD format at www.nrd.ca.
Submit this form in a format other than NRD format to report changes to information in a:
a) Form 33-109F6, or
b) Form 33-109F4, if the individual is relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database.
Name of firm
______________________________
Registration categories
______________________________
NRD number (firm) ____________________
Item 1 Type of form
Check the form that is being updated:
[ ] Form 33-109F6
If submitting changes to Form 33-109F6, please attach a blackline of the amended sections of the form.
[ ] Form 33-109F4 Name of individual
Item 2 Details of change
Provide the item number and details for each change to the form selected above:
Item number __________ Details __________
Effective date of change ____________________ (YYYY/MM/DD)
Item 3 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 in the jurisdictions set out in Schedule A to administer and enforce certain provisions of their securities legislation or derivatives legislation or both.
The personal information required under this form is also collected by and used by the SRO set out in Schedule A to administer and enforce its by-laws, regulations, rules, rulings and policies.
By submitting this form, the individual consents to the collection by the securities regulatory authorities or applicable SRO of this personal information, and any police records, records from other government or non-governmental regulators or SROs, credit records and employment records about the individual that the securities regulatory authorities or applicable SRO may need to complete their review of the information submitted in this form relating to the individual's continued fitness for registration or approval, if applicable, in accordance with the legal authority of the securities regulatory authorities while the individual is registered with or approved by it. Securities regulatory authorities or SROs may contact government and private bodies or agencies, individuals, corporations and other organizations for information about the individual.
If you have any questions about the collection and use of this information, contact the securities regulatory authorities or applicable SRO in any jurisdiction in which the required information is submitted. See Schedule A for details. In Québec, you can also contact the Commission d'accès à l'information at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca.
Item 3 Notice and consent for collection and use of personal information
1. Notice of collection and use of personal information
Your personal information is collected by, or on behalf of, each securities regulatory authority and SRO set out in Schedule A. Any of the securities regulatory authorities, or SROs set out in Schedule A may contact governmental or regulatory authorities, private bodies or agencies, individuals, corporations, employers, and other organizations, in Canada and in other countries, for information about you.
This personal information is being collected under the authority of the applicable securities legislation, derivatives legislation (including commodity futures legislation) or both of the securities regulatory authorities and under the SRO rules of an SRO set out in Schedule A. The collection, use and disclosure are done in accordance with applicable freedom of information and privacy legislation.
The principal purpose of this collection by the securities regulatory authorities is to administer, enforce, carry out their duties or exercise their powers under their respective securities legislation, derivatives legislation (including commodity futures legislation) or both, and by the SROs to administer and enforce the rules of the SROs.
The information submitted by you in this form with your consent, or collected indirectly with your authorization, may be collected
• at any time during your registration or while you are a permitted individual, or
• at the time the regulator or, in Québec, the securities regulatory authority, or the SRO is informed by your sponsoring firm that you no longer have authority to act on behalf of the sponsoring firm or are not a permitted individual of the sponsoring firm.
If you have any questions about the collection, use and disclosure of this information, contact the securities regulatory authority or SRO in any jurisdiction in which the required information is submitted. See Schedule A for details.
Certain information, such as your name(s) (including aliases, trade names or some past names), your sponsoring firm, and other relevant registration information, will be listed in a publicly available registry of registered individuals and, if applicable, on the Disciplined List.
Certain securities regulatory authorities may provide to or receive from certain entities information under separate provisions of their securities legislation or derivatives legislation (including commodity futures legislation) or both, and SROs may provide or receive information under the rules of the SROs. This consent and notice does not limit the authority, powers, obligations or rights conferred on any of the securities regulatory authorities by legislation or regulations in effect in their jurisdiction.
2. Consent to collect and use personal information
By submitting this form, you consent to and authorize the collection, directly and indirectly, of personal information by each securities regulatory authority and SRO and to the use of your personal information as set out above.
The personal information that each securities regulatory authority or SRO collects includes the following:
• the personal information provided in this form;
• the personal information provided by your sponsoring firm;
• registration or financial services licensing information;
• law enforcement records, including police records;
• credit records;
• bankruptcy or other insolvency records;
• employment records and information received from an employer;
• records and information received from entities you had or have an independent contractor or agency relationship with;
• personal information available online;
• records from governmental or regulatory authorities, SROs or professional bodies;
• records of, and used in, court proceedings, including probation records.
Item 4 Warning[repealed]
It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.
Item 5 Certification[repealed]
1. Use the following certification when submitting this form in NRD format when making changes to Form 33-109F4
I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm. To the best of my knowledge and belief, the officer, branch manager or supervisor was satisfied that I fully understood the questions. I will limit my activities to those permitted by my category of registration.
[ ] I am making this submission as agent for the individual identified in this form. By checking this box, I certify that the individual provided me with all of the information on this form.
2. Use the following certification when submitting this form in a format other than NRD format when making changes to Form 33-109F6
By signing below I certify to each regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form, either directly or through the principal regulator, that:
• I have read this form and understand the questions, and
• all of the information provided on this form is true, and complete.
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
3. Use the following certification when submitting this form in a format other than NRD format under the temporary hardship exemption in section 5.1 of NI 31-102 National Registration Database when making changes to Form 33-109F4
By signing below, I certify to the regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form, either directly or through the principal regulator, that:
• I have read this form and understand the questions; and
• all of the information provided on this form is true and complete.
Signature of individual ____________________
Date signed ____________________ (YYYY/MM/DD)
Schedule A Contact information for Notice of notice and consent for collection and use of personal information
|
Alberta |
Nunavut |
|
Alberta Securities Commission, |
Government of Nunavut |
|
Suite 600, 250-5th St. SW |
Department of Justice |
|
Calgary, AB T2P 0R4 |
P.O. Box 1000 Station 570 |
|
Attention: Information Officer |
Iqaluit, NU X0A 0H0 |
|
Telephone: (403) 297-6454 |
Attention: Deputy Registrar of Securities |
|
Telephone: (867) 975-6590 |
|
|
|
|
|
British Columbia |
Ontario |
|
British Columbia Securities Commission |
Ontario Securities Commission |
|
P.O. Box 10142, Pacific Centre |
22nd Floor |
|
701 West Georgia Street |
20 Queen Street West |
|
Vancouver, BC V7Y 1L2 |
Toronto, ON M5H 3S8 |
|
Attention: |
Attention: Compliance and Registrant Regulation |
|
Telephone: (604) 899-6500 or (800) 373-6393 (in Canada) |
Telephone: (416) 593-8314 |
|
E-mail: [email protected] |
E-mail: [email protected] |
|
|
|
|
Manitoba |
Prince Edward Island |
|
The Manitoba Securities Commission |
Securities Office |
|
500 -- 400 St. Mary Avenue |
Department of Community Affairs and Attorney |
|
Winnipeg, MB R3C 4K5 |
P.O. Box 2000 |
|
Attention: Director of Registrations |
Charlottetown, PE C1A 7N8 |
|
Telephone: (204) 945-2548 |
Attention: Deputy Registrar of Securities |
|
Fax (204) 945-0330 |
Telephone: (902) 368-6288 |
|
|
|
|
New Brunswick |
Québec |
|
Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick |
Autorité des marchés financiers |
|
Suite 300, 85 Charlotte Street |
800, square Victoria, 22e étage |
|
Saint John, NB E2L 2J2 |
C.P. 246, tour de la Bourse |
|
Attention: Director of Securities |
Montréal (Québec) H4Z 1G3 |
|
Telephone: (506) 658-3060 |
Attention: Responsable de l'accès à l'information |
|
Telephone: (514) 395-0337 or (877) 525-0337 |
|
|
|
|
|
Newfoundland and Labrador |
Saskatchewan |
|
Superintendent of Securities, Service NL |
Financial and Consumer Affairs Authority of Saskatchewan |
|
Government of Newfoundland and Labrador |
Suite 601, 1919 Saskatchewan Drive |
|
P.O. Box 8700 |
Regina, SK S4P 4H2 |
|
2nd Floor, West Block |
Attention: |
|
Confederation Building |
Telephone: (306) 787-5871 |
|
St. John's, NL A1B 4J6 |
E-mail: [email protected] |
|
Attention: Manager of Registrations |
|
|
Telephone: (709) 729-5661 |
|
|
|
|
|
Nova Scotia |
Yukon |
|
Nova Scotia Securities Commission |
Government of Yukon |
|
Suite 400, 5251 Duke Street |
Office of the Yukon Superintendent of Securities |
|
Halifax, NS B3J 1P3 |
Department of Community Services |
|
Attention: |
P.O. Box 2703 C-6 |
|
Telephone: (902) 424-7768 |
Whitehorse, YT Y1A 2C6 |
|
Attention: Superintendent of Securities |
|
|
Telephone: |
|
|
|
|
|
Northwest Territories |
Self-regulatory organization |
|
Government of the Northwest Territories |
Investment Industry Regulatory Organization of Canada |
|
Department of Justice |
121 King Street West, Suite 2000 |
|
1st Floor Stuart M. Hodgson Building |
Toronto, Ontario M5H 3T9 |
|
5009 -- 49th Street |
Attention: Privacy Officer |
|
Yellowknife, NWT X1A 2L9 |
Telephone: (416) 364-6133 |
|
Attention: |
E-mail: [email protected] |
|
Telephone: (867) 920-8984 |
|
FORM 33-109F6 FIRM REGISTRATION
Who should complete this form?
This form is for firms seeking registration under securities legislation, derivatives legislation or both.
Complete and submit this form to seek initial registration as a dealer, adviser or investment fund manager, or to add one or more jurisdiction of Canada or categories to a firm's registration.
Definitions
In this form:
Chief compliance officer -- see section 2.1 of NI 31-103.
Derivatives -- financial instruments, such as futures contracts (including exchange traded contracts), futures options and swaps whose market price, value or payment obligations are derived from or based on one or more underlying interests. Derivatives can be in the form of instruments, agreements or securities.
Firm -- the person or company seeking registration.
Foreign jurisdiction -- see National Instrument 14-101 Definitions.
Form -- Form 33-109F6 Firm Registration.
Jurisdiction or jurisdiction of Canada -- see National Instrument 14-101 Definitions.
NI 31-103 -- National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations.
NI 33-109 -- National Instrument 33-109 Registration Information.
NI 52-107 -- National Instrument 52-107 Acceptable Accounting Principles and Auditing Standards.
NRD -- National Registration Database. For more information, visit www.nrd-info.ca.
Parent -- a person or company that directly or indirectly has significant control of another person or company.
Permitted individual -- see NI 33-109.
Predecessor -- any entity listed in question 3.6 of this form.
Principal regulator -- see NI 33-109.
Significant control -- a person or company has significant control of another person or company if the person or company:
• directly or indirectly holds voting securities representing more than 20 per cent of the outstanding voting rights attached to all outstanding voting securities of the other person or company, or
• directly or indirectly is able to elect or appoint a majority of the directors (or individuals performing similar functions or occupying similar positions) of the other person or company.
Specified affiliate -- a person or company that is a parent of the firm, a specified subsidiary of the firm, or a specified subsidiary of the firm's parent.
Specified subsidiary -- a person or company of which another person or company has significant control.
SRO -- see National Instrument 14-101 Definitions.
Ultimate designated person -- see section 2.1 of NI 31-103.
You -- the individual who completes, submits, files and/or signs the form on behalf of the firm.
We and the regulator -- the securities regulatory authority or regulator in the jurisdiction(s) of Canada where the firm is seeking registration.
Contents of the form
This form consists of the following:
Part 1 -- Registration details
Part 2 -- Contact information
Part 3 -- Business history and structure
Part 4 -- Registration history
Part 5 -- Financial condition
Part 6 -- Client relationships
Part 7 -- Regulatory action
Part 8 -- Legal action
Part 9 -- Certification
Schedule A -- Contact information for notice of collection and use of personal information
Schedule B -- Submission to jurisdiction and appointment of agent for service
Schedule C -- Form 31-103F1 Calculation of excess working capital
This form consists of the following:
Collection and use of personal information
Certification
Part 1 -- Registration details
Part 2 -- Contact information
Part 3 -- Business history and structure
Part 4 -- Registration history
Part 5 -- Financial condition
Part 6 -- Client relationships
Part 7 -- Regulatory action
Part 8 -- Legal action
Part 9 -- [repealed]
Schedule A -- Contact information for consent and notice of collection and use of personal information
Schedule B -- Submission to jurisdiction and appointment of agent for service
Schedule C -- Form 31-103F1 Calculation of excess working capital
You are also required to submit the following supporting documents with your completed form:
1. Schedule B -- Submission to jurisdiction and appointment of agent for service for each jurisdiction where the firm is seeking registration (question 2.4)
2. Business plan, policies and procedures manual, and client agreements (except in Ontario) (question 3.3)
3. Constating documents (question 3.7)
4. Organization chart (question 3.11)
5. Ownership chart (question 3.12)
6. Calculation of excess working capital (question 5.1)
7. Directors' resolution approving insurance (question 5.7)
8. Audited financial statements (question 5.13)
9. Letter of direction to auditors (question 5.14)
The firm is required to pay a registration fee in each jurisdiction of Canada where it is submitting and filing this form. Refer to the prescribed fees of the applicable jurisdiction for details.
How to complete and submit the form
All dollar values are in Canadian dollars. If a question does not apply to the firm, write "n/a" in the space for the answer.
If the firm is seeking registration in more than one jurisdiction of Canada or category, other than in the category of restricted dealer, you only need to complete and submit one form. If the firm is seeking registration as a restricted dealer, submit and file the form with each jurisdiction of Canada where the firm is seeking that registration.
You can complete this form:
• on paper and deliver it to the principal regulator or relevant SRO
• on paper, scan it and e-mail it to the principal regulator or SRO
If the firm is seeking registration in Ontario, and Ontario is not the firm's principal regulator, you must also file a copy of this form, without supporting documents, with the Ontario Securities Commission.
You can find contact information for submitting and filing the form in Appendix B of Companion Policy 33-109CP Registration Information.
We may accept the form in other formats. Please check with the regulator before you complete, submit and file the form. If you are completing the form on paper and need more space to answer a question, use a separate sheet of paper and attach it to this form. Clearly identify the question number.
You must include all supporting documents with your submission. We may ask you to provide other information and documents to help determine whether the firm is suitable for registration.
In most of this form, answers are required to questions that apply only to Canadian provinces and territories; you will find that the questions are referenced to "jurisdictions" or "jurisdiction of Canada". These refer to all provinces and territories of Canada. However, the questions in Part 4 -- Registration History and Part 7 -- Regulatory Action are to be answered in respect of any jurisdiction in the world.
It is an offence to knowingly give false or misleading information on this formto the regulator or securities regulatory authority.
See Part 3 of NI 33-109.
Updating the information on the form
The firm is required to notify the regulator, within specified times, of any changes to the information on this form by submitting and filing Form 33-109F5 Change of Registration Information.
Collection and use of personal information
We and the SROs (if applicable) require personal information about the people referred to in this form as part of our review to determine whether the firm is suitable for registration. If the firm is approved, we also require this information to assess whether the firm continues to meet the registration requirements.
We may only:
• collect the personal information under the requirements in securities legislation or derivatives legislation or both
• use this information to administer and enforce provisions of the securities legislation or derivatives legislation or both
We may collect personal information from police records, records of other regulators or SROs, credit records, employment records, government and private bodies or agencies, individuals, corporations, and other organizations. We may also collect personal information indirectly.
We may provide personal information about the individuals referred to in this form to other regulators, securities or derivatives exchanges, SROs or similar organizations, if required for an investigation or other regulatory issue.
If anyone referred to in this form has any questions about the collection and use of their personal information, they can contact the regulator or SRO, if applicable, in the relevant jurisdiction of Canada. See Schedule A for details. In Québec, they can also contact the Commission d'accès à l'information du Québec at 1-888-528-7741 or visit its website atwww.cai.gouv.qc.ca.
In obtaining information about the firm, each securities regulatory authority and SRO set out in Appendix A may receive and collect personal information about individuals, if any, associated with the firm and its directors, officers, partners, employees, contractors and agents.
This may include the collection of
• the personal information provided in this form,
• registration or financial services licensing information,
• personal information available online,
• records from governmental or regulatory authorities, SROs or professional bodies, or
• records of, and used in, court proceedings, including probation records.
Any of the securities regulatory authorities or SROs set out in Schedule A may contact governmental or regulatory authorities, private bodies or agencies, individuals, corporations, employers, and other organizations, in Canada and in other countries, for information about the individual.
This personal information is being collected under the authority of the applicable securities legislation, derivatives legislation (including commodity futures legislation), or both of the securities regulatory authorities and under the SRO rules of an SRO set out in Schedule A. The collection, use and disclosure are done in accordance with applicable freedom of information and privacy legislation.
The principal purpose of this collection by the securities regulatory authorities is to administer, enforce, carry out their duties or exercise their powers under their respective securities legislation, derivatives legislation (including commodity futures legislation) or both, and for the SROs to administer and enforce the rules of the SROs.
The information may be collected
• at the time of the firm's application,
• at any time during the firm's registration, or
• at the time the regulator or, in Québec, the securities regulatory authority, or the SRO is informed by the firm that it is surrendering its registration.
If you or anyone referred to in this form has any questions about the collection, use, and disclosure of this information, you or they can contact the regulator or, in Québec, the securities regulatory authority, or SRO in any jurisdiction in which the required information is submitted. See Schedule A for details.
Certain registration information about the firm and its registered individuals will be listed in a publicly available registry, including names used by the firm, the address of the firm's head office, whether the firm is on the Disciplined List, the jurisdictions and categories in which the firm is registered, and whether any terms and conditions have been imposed on the firm's registration, and the firm's registered individuals.
Certain securities regulatory authorities may provide to or receive from certain entities information under separate provisions of their securities legislation or derivatives legislation (including commodity futures legislation) or both, and SROs may provide or receive information under the rules of the SROs. This consent and notice does not limit the authority, powers, obligations, or rights conferred on any of the securities regulatory authorities by legislation or regulations in effect in their jurisdiction.
WARNING: It is an offence to knowingly give false or misleading information to the regulator or the securities regulatory authority.
CERTIFICATION
By signing this form, I, on behalf of the firm,
1. certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm is submitting this form and to any applicable self-regulatory organization (SRO) that
• I have read this form,
• the firm has submitted and filed all information required to be submitted and filed under securities legislation and/or derivatives legislation in the principal jurisdiction of Canada where the firm is seeking registration, and
• to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete,
2. authorize the principal regulator to give each non-principal regulator and, where applicable, SRO access to any information the firm has submitted or filed with the principal regulator under securities legislation or derivatives legislation or both in relation to the firm's registration in that jurisdiction,
3. acknowledge that the regulator or, in Québec, the securities regulatory authority, and SRO may collect and provide personal information about the individuals referred to in this form under the heading Collection and Use of Personal Information, and
4. confirm that the individuals referred to in this form have been notified that the individuals' personal information is disclosed on this form, the legal reason for doing so, how it will be used and who to contact for more information.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
For more information, visit www.nrd-info.ca.
Part 1 -- Registration details
1.1 Firm's full legal name
Provide the full legal name of the firm as it appears on the firm's constating documents required under question 3.7. If the firm is a sole proprietorship, provide your first, last and any middle names.
If the firm's legal name is in English and French, provide both versions.
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
1.2 Firm's NRD number
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
1.3 Why are you submitting this form?
|
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|
Complete: |
|
|
||
|
[ ] |
To seek initial registration as a firm in one or more jurisdictions of Canada |
The entire form |
|
|
||
|
[ ] |
To add one or more jurisdictions of Canada to the firm's registration |
Questions 1.1, 1.2, 1.4, 1.5, 2.4, 3.9, 5.4, 5.6{*}, and Part 9 |
|
|
||
|
[ ] |
To add one or more categories to the firm's registration |
Questions 1.1, 1.2, 1.4, 1.5, 3.1, 5.1, 5.4,5.5, 5.6{*}, 5.7, 5.8, Part 6 and Part 9 |
{*} If the firm is adding Québec as a jurisdiction for registration in the category of mutual fund dealer or scholarship plan dealer, complete question 5.6.
Abbreviations
Alberta (AB) British Columbia (BC) Manitoba (MB) New Brunswick (NB) Newfoundland and Labrador (NL) Northwest Territories (NT) Nova Scotia (NS) Nunavut (NU) Ontario (ON) Prince Edward Island (PE) Québec (QC) Saskatchewan (SK) Yukon (YT)
1.4 In what category and jurisdiction is the firm seeking registration? Check all that apply.
(a) Categories under securities legislation
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Jurisdiction |
||||||||||||
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|
Category |
AB |
BC |
MB |
NB |
NL |
NS |
NT |
NU |
ON |
PE |
QC |
SK |
YT |
|
|
|||||||||||||
|
Investment dealer |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
|
|
|||||||||||||
|
Mutual fund dealer |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
|
|
|||||||||||||
|
Scholarship plan dealer |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
|
|
|||||||||||||
|
Exempt market dealer |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
|
|
|||||||||||||
|
Restricted dealer |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
|
|
|||||||||||||
|
Investment fund manager |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
|
|
|||||||||||||
|
Portfolio manager |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
|
|
|||||||||||||
|
Restricted portfolio manager |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
(b) Categories under derivatives legislation (Manitoba and Ontario only)
|
Category |
Manitoba |
|
|
|
|
Dealer (merchant) |
[ ] |
|
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|
|
Dealer (futures commission merchant) |
[ ] |
|
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|
|
Dealer (floor broker) |
[ ] |
|
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Local |
[ ] |
|
|
|
|
Adviser |
[ ] |
|
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|
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Ontario |
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Commodity trading adviser |
[ ] |
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Commodity trading counsel |
[ ] |
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Commodity trading manager |
[ ] |
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Futures commission merchant |
[ ] |
(c) Investment dealers and portfolio managers (Québec only)
If the firm is seeking registration in Québec as an investment dealer or a portfolio manager, will the firm alsact as a:
Derivatives dealer
Yes
[ ]
No
[ ]
Derivatives portfolio manager
Yes
[ ]
No
[ ]
1.5 Exemptions
Is the firm applying for any exemptions under securities or derivatives legislation?
Yes [ ] No [ ]
If yes, provide the following information for each exemption:
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Type of exemption |
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Legislation |
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Jurisdiction(s) where the firm has applied for the exemption |
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AB |
BC |
MB |
NB |
NL |
NS |
NT |
NU |
ON |
PE |
QC |
SK |
YT |
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[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
Part 2 -- Contact information
Addresses
A post office box on its own is not acceptable for a head office address.
2.1 Head office address
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Address line 1 |
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Address line 2 |
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City |
Province/territory/state |
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Country |
Postal/zip code |
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Telephone number |
Fax number |
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Website |
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If the firm's head office is in Canada, go to question 2.3.
If the firm's head office is not in Canada, go to question 2.2.
2.2 Firms whose head office is not in Canada
(a) Does the firm have any business location addresses in Canada?
Yes [ ] No [ ]
If yes, provide the firm's primary Canadian business location address:
Address line 1
Address line 2
City
Province/territory
Postal code
The securities regulatory authority in this jurisdiction of Canada is the firm's principal regulator in Canada.
(b) If a firm is not registered in a jurisdiction of Canada, indicate the jurisdiction of Canada in which the firm expects to conduct most of its activities that require registration as at the end of its current financial year or conducted most of its activities that require registration as at the end of its most recently completed financial year.
|
AB |
BC |
MB |
NB |
NL |
NS |
NT |
NU |
ON |
PE |
QC |
SK |
YT |
|
|
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[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
[ ] |
A post office box is acceptable for a mailing address.
2.3 Mailing address
[ ] Same as the head office address
|
Address line 1 |
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Address line 2 |
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City |
Province/territory/state |
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Country |
Postal/zip code |
If the firm does not have an office in a jurisdiction of Canada where it is seeking registration, it must appoint an agent for service in that jurisdiction of Canada.
2.4 Address for service and agent for service
Attach a completed Schedule B an executed Schedule B Submission to jurisdiction and appointment of agent for service for each jurisdiction of Canada where the firm is seeking registration and does not have an office.
Contact names
A registered firm must have an individual registered in the category of ultimate designated person.
2.5 Ultimate designated person
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Legal name |
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Officer title |
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Telephone number |
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E-mail address |
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NRD number, if available |
||
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||
|
Address |
||
|
[ ] |
Same as firm head office address |
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|
Address line 1 |
||
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||
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Address line 2 |
||
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|
||
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City |
Province/territory/state |
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Country |
Postal/zip code |
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A registered firm must have an individual registered in the category of chief compliance officer.
2.6 Chief compliance officer
[ ] Same as ultimate designated person
|
Legal name |
||
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||
|
Officer title |
||
|
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||
|
Telephone number |
||
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||
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E-mail address |
||
|
|
||
|
NRD number, if available |
||
|
|
||
|
Address |
||
|
|
||
|
[ ] |
Same as firm head office address |
|
|
|
||
|
Address line 1 |
||
|
|
||
|
Address line 2 |
||
|
|
||
|
City |
Province/territory/state |
|
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Country |
Postal/zip code |
|
Part 3 -- Business history and structure
Business activities
3.1 The firm's business
Provide a description of the firm's proposed business, including its primary business activities, target market, and the products and services it will provide to clients.
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
3.2 Other names
In addition to the firm's legal name in question 1.1, does the firm use any other names, such as a trade name?
Yes [ ] No [ ]
If yes, list all other names and indicate if each name has been registered:
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
3.3 Business documents
Does the firm have the following documents to support its business activities?
|
|
|
Yes |
No |
|
|
|||
|
(a) |
Business plan for at least the next three years |
_____ |
_____ |
|
|
|||
|
(b) |
Policies and procedures manual, including account opening procedures and the firm's policy on fairness in allocation of investment opportunities, if applicable |
_____ |
_____ |
If no, explain why the firm does not have the document:
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
Attach the firm's business plan, policies and procedures manual and client agreements, including any investment policy statements and investment management agreements, except if the regulator in Ontario is the principal regulator of the firm seeking registration, unless the regulator in Ontario has requested they be provided.
History of the firm
3.4 When was the firm created?
- - - - - - - - - - - - - - - - - - - -
yyyy/mm/dd
- - - - - - - - - - - - - - - - - - - -
3.5 How was the firm created?
|
New start-up |
[ ] |
Go to question 3.7. |
|
Merger or amalgamation |
[ ] |
Go to question 3.6. |
|
Reorganization |
[ ] |
Go to question 3.6. |
|
Other statutory arrangement |
[ ] |
Please specify below and go to question 3.6. |
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
3.6 Predecessors
List the entities that were merged, amalgamated, reorganized or otherwise arranged to create the firm.
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
3.7 Constating documents
Attach the legal documents that established the firm as an entity, for example, the firm's articles and certificate of incorporation, any articles of amendments, partnership agreement or declaration of trust. If the firm is a sole proprietorship, provide a copy of the registration of trade name.
As part of their constating documents, firms whose head office is outside Canada may be required to provide proof of extra-provincial registration.
Business structure and ownership
3.8 Type of legal structure
|
Sole proprietorship |
[ ] |
|
|
Partnership |
[ ] |
|
|
Limited partnership |
[ ] |
Name of general partner __________ |
|
Corporation |
[ ] |
|
|
Other |
[ ] |
Please specify ____________________ |
This is the firm's corporate registration number or Québec enterprise number (NEQ).
3.9 Business registration number, if applicable
List the firm's business registration number for each jurisdiction of Canada where the firm is seeking registration.
|
Business registration number |
Jurisdiction of Canada |
|
|
|
|
____________________ |
____________________ |
3.10 Permitted individuals
List all permitted individuals of the firm.
|
|
|
|
|
|
||
|
__________ |
__________ |
__________ |
3.10 Permitted individuals
List all permitted individuals of the firm.
State why the individual is considered a permitted individual (e.g., director, partner, officer, shareholder, or a permitted individual as described in paragraph (c) of the definition of "permitted individual" in section 1.1 of National Instrument 33-109 Registration Information).
|
Name |
Type of Permitted Individual |
NRD number, if applicable |
|
|
||
|
__________ |
__________ |
__________ |
3.11 Organization chart
Attach an organization chart showing the firm's reporting structure. Include all permitted individuals, the ultimate designated person and the chief compliance officer.
3.12 Ownership chart
Attach a chart showing the firm's structure and ownership. At a minimum, include all parents, specified affiliates and specified subsidiaries.
Include the name of the person or company, and class, type, amount and voting percentage of ownership of the firm's securities.
3.12 Ownership chart
Attach a chart showing the firm's structure and ownership. Include all parents, specified affiliates and specified subsidiaries. Indicate which of the parents, specified affiliates and specified subsidiaries are registered under securities legislation in any jurisdiction of Canada and provide their NRD number.
Include the name of the person or company, and class, type, amount and percentage ownership of the firm's voting securities.
Part 4 -- Registration history
The questions in Part 4 apply to any jurisdiction and any foreign jurisdiction.
4.1 Securities registration
In the last seven years, has the firm, or any predecessors or specified affiliates of the firm been registered or licensed to trade or advise in securities or derivatives?
Yes [ ] No [ ]
If yes, provide the following information for each registration:
Name of entity
Registration category
Regulator/organization
Date registered or licensed (yyyy/mm/dd)
Expiry date, if applicable (yyyy/mm/dd)
Jurisdiction
4.2 Exemption from securities registration
Is the firm currently relying on any exemptions from registration or licensing to trade or advise in securities or derivatives?
Yes [ ] No [ ]
If yes, provide the following information for each exemption:
- - - - - - - - - - - - - - - - - - - -
Type of exemption
Regulator/organization
Date of exemption (yyyy/mm/dd)
Jurisdiction
- - - - - - - - - - - - - - - - - - - -
4.3 Membership in an exchange or SRO
In the last seven years, has the firm, or any predecessors or specified affiliates of the firm been a member of a securities or derivatives exchange, SRO or similar organization?
Yes [ ] No [ ]
If yes, provide the following information for each membership:
Name of entity
Organization
Date of membership (yyyy/mm/dd)
Expiry date, if applicable (yyyy/mm/dd)
Jurisdiction
4.4 Exemption from membership in an exchange or SRO
Is the firm currently relying on any exemptions from membership with a securities or derivatives exchange, SRO or similar organization?
Yes [ ] No [ ]
If yes, provide the following information for each exemption:
- - - - - - - - - - - - - - - - - - - -
Type of exemption
Organization
Date of exemption (yyyy/mm/dd)
Jurisdiction
- - - - - - - - - - - - - - - - - - - -
4.5 Refusal of registration, licensing or membership
Has the firm, or any predecessors or specified affiliates of the firm been refused registration, licensing or membership with a financial services regulator, securities or derivatives exchange, SRO or similar organization?
Yes [ ] No [ ]
If yes, provide the following information for each refusal:
- - - - - - - - - - - - - - - - - - - -
Name of entity
Reason for refusal
Regulator/organization
Date of refusal (yyyy/mm/dd)
Jurisdiction
- - - - - - - - - - - - - - - - - - - -
Examples of other financial products include financial planning, life insurance and mortgages.
4.6 Registration for other financial products
In the last seven years, has the firm, or any predecessors or specified affiliates of the firm been registered or licensed under legislation that requires registration or licensing to sell or advise in a financial product other than securities or derivatives?
Yes [ ] No [ ]
If yes, provide the following information for each registration or licence:
Name of entity
Type of licence or registration
Regulator/organization
Date of registration (yyyy/mm/dd)
Expiry date, if applicable (yyyy/mm/dd)
Jurisdiction
Name of entity
Type of licence or registration
Licence number
Regulator/organization
Date of registration (yyyy/mm/dd)
Expiry date, if applicable (yyyy/mm/dd)
Jurisdiction
Part 5 -- Financial condition
Capital requirements
5.1 Calculation of excess working capital
Attach the firm's calculation of excess working capital.
• Investment dealers must use the capital calculation form required by the Investment Industry Regulatory Organization of Canada (IIROC).
• Mutual fund dealers must use the capital calculation form required by the Mutual Fund Dealers Association of Canada (MFDA), except for mutual fund dealers registered in Québec only.
• Firms that are not members of either IIROC or the MFDA must use Form 31-103F1 Calculation of Excess Working Capital. See Schedule C.
5.2 Sources of capital
List all cash, cash equivalents, debt and equity sources of the firm's capital.
|
Name of person or entity providing the capital |
Type of capital |
Amount ($) |
|
|
||
|
__________ |
__________ |
__________ |
See Schedule C Form 31-103F1 Calculation of Excess Working Capital.
5.3 Guarantors
In relation to its business, does the firm:
Yes
No
(a)
Have any guarantors?
_____
_____
(b)
Act as a guarantor for any party?
_____
_____
If yes, provide the following information for each guarantee:
Name of party to the guarantee
NRD number, if applicable
Relationship to the firm
Amount of guarantee ($)
Details of the guarantee
Bonding and insurance
Questions 5.4 to 5.8 apply to the firm's bonding or insurance coverage or proposed bonding or insurance coverage for securities and derivatives activities only. This in accordance with Part 12, Division 2 of NI 31-103.
This information is on the financial institution bond.
5.4 Jurisdictions covered
Where does the firm have bonding or insurance coverage?
|
AB |
[ ] |
|
BC |
[ ] |
|
MB |
[ ] |
|
NB |
[ ] |
|
NL |
[ ] |
|
NS |
[ ] |
|
NT |
[ ] |
|
NU |
[ ] |
|
ON |
[ ] |
|
PE |
[ ] |
|
QC |
[ ] |
|
SK |
[ ] |
|
YT |
[ ] |
If the firm's bonding or insurance does not cover all jurisdictions of Canada where it is seeking registration, explain why.
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
This information is on the binder of insurance or on the financial institution bond.
5.5 Bonding or insurance details
|
Name of insurer |
|
|
|
|
|
Bond or policy number |
|
|
|
|
|
Specific insuring agreements and clauses |
|
|
|
|
|
Coverage for each claim ($) |
Annual aggregate coverage ($) |
|
|
|
|
Total coverage ($) |
|
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|
|
Amount of the deductible ($) |
Expiry date (yyyy/mm/dd) |
If the firm's insurance or proposed insurance is not in the form of a financial institution bond, explain how it provides equivalent coverage to the bond.
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
This information is required only if the firm is applying for registration in Québec as a mutual fund dealer or as a scholarship plan dealer.
5.6 Professional liability insurance (Québec only)
If the firm is seeking registration in Québec as a mutual fund dealer or a scholarship plan dealer, provide the following information about the firm's professional liability insurance:
Name of insurer
Policy number
Specific insuring agreements and clauses
Coverage for each claim ($)
Annual aggregate coverage ($)
Total coverage ($)
Amount of the deductible ($)
Renewal date (yyyy/mm/dd)
Jurisdictions covered:
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
Which insurance policy applies to your representatives?
Firm's policy
[ ]
Individual's policy
[ ]
Both
[ ]
5.7 Directors' resolution approving insurance
Attach a directors' resolution confirming that the firm has sufficient insurance coverage for its securities or derivatives-related activities.
5.8 Bonding or insurance claims
In the last seven years, has the firm made any claims against a bond or on its insurance?
Yes [ ] No [ ]
If yes, provide the following information for each claim:
Type of bond or insurance
Date of claim (yyyy/mm/dd)
Amount ($)
Reason for claim
Date resolved (yyyy/mm/dd)
Result
Jurisdiction
Solvency
5.9 Bankruptcy
In the last seven years, has the firm or any of its specified affiliates declared bankruptcy, made an assignment or proposal in bankruptcy, or been the subject of a petition in bankruptcy, or the equivalent in any jurisdiction?
Yes [ ] No [ ]
If yes, provide the following information for each bankruptcy or assignment in bankruptcy:
Name of entity
Reason for bankruptcy or assignment
Date of bankruptcy, assignment or petition (yyyy/mm/dd)
Date discharge granted, if applicable (yyyy/mm/dd)
Name of trustee
Jurisdiction
If applicable, attach a copy of any discharge, release or equivalent document.
5.10 Appointment of receiver
In the last seven years, has the firm or any of its specified affiliates appointed a receiver or receiver manager, or had one appointed, or the equivalent in any jurisdiction?
Yes [ ] No [ ]
If yes, provide the following information for each appointment of receiver:
Name of entity
Date of appointment (yyyy/mm/dd)
Reason for appointment
Date appointment ended (yyyy/mm/dd)
Reason appointment ended
Name of receiver or receiver manager
Jurisdiction
Financial reporting
5.11 Financial year-end
- - - - - - - - - - - - - - - - - - - -
(mm/dd)
- - - - - - - - - - - - - - - - - - - -
If the firm has not established its financial year-end, explain why.
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
Provide the name of the individual auditing the financial statements and the name of the firm, if applicable.
5.12 Auditor
- - - - - - - - - - - - - - - - - - - -
Name of auditor and accounting firm
- - - - - - - - - - - - - - - - - - - -
5.13 Audited financial statements
(a) Attach, for your most recently completed year, either
(i) non-consolidated audited financial statements; or
(ii) audited financial statements prepared in accordance with section 3.2(3) of NI 52-107.
(b) If the audited financial statements attached for item (a) were prepared for a period ending more than 90 days before the date of this application, also attach
an interim financial reportinterim financial information (as set out in section 12.11 of NI 31-103) for a period of not more than 90 days before the date of this application.
If the firm is a start-up company, you can attach an audited opening statement of financial position instead.
We may request an audit of the firm at any time while the firm is registered.
5.14 Letter of direction to auditors
Attach a letter of direction from the firm authorizing the auditor to conduct any audit or review of the firm that the regulator may request.
Part 6 -- Client relationships
See Part 14, Division 3 of NI 31-103 and Companion Policy 31-103CP.
For guidance regarding whether a firm will hold or have access to client assets see section 12.4 of Companion Policy 31-103CP.
6.1 Client assets
Will the firm hold or have access to client assets?
Yes [ ] No [ ]
If yes, provide the following information for each financial institution where the trust accounts for client assets are held.
|
Name of financial institution |
|
|
|
|
|
Address line 1 |
|
|
|
|
|
Address line 2 |
|
|
|
|
|
City |
Province/territory |
|
|
|
|
Postal code |
Telephone number |
6.2 Conflicts of interest
Does the firm have or expect to have any relationships that could reasonably result in any significant conflicts of interest in carrying out its registerable activities in accordance with securities or derivatives legislation?
Yes [ ] No [ ]
If yes, complete the following questions:
(a) Provide details about each conflict:
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
(b) Does the firm have policies and procedures to identify and respond to its conflicts of interest?
Yes [ ] No [ ]
If no, explain why:
- - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - -
Part 7 -- Regulatory action
The questions in Part 7 apply to any jurisdiction and any foreign jurisdiction. The information must be provided in respect of the last 7 years.
7.1 Settlement agreements
Has the firm, or any predecessors or specified affiliates of the firm entered into a settlement agreement with any financial services regulator, securities or derivatives exchange, SRO or similar organization?
Yes [ ] No [ ]
If yes, provide the following information for each settlement agreement:
- - - - - - - - - - - - - - - - - - - -
Name of entity
Regulator/organization
Date of settlement (yyyy/mm/dd)
Details of settlement
Jurisdiction
- - - - - - - - - - - - - - - - - - - -
7.2 Disciplinary history
Has any financial services regulator, securities or derivatives exchange, SRO or similar organization:
Yes
No
Determined that the firm, or any predecessors or specified affiliates of the firm violated any securities regulations or any rules of a securities or derivatives exchange, SRO or similar organization?
_____
_____
Determined that the firm, or any predecessors or specified affiliates of the firm made a false statement or omission?
_____
_____
Issued a warning or requested an undertaking by the firm, or any predecessors or specified affiliates of the firm?
_____
_____
Suspended or terminated any registration, licensing or membership of the firm, or any predecessors or specified affiliates of the firm?
_____
_____
Imposed terms or conditions on any registration or membership of the firm, or predecessors or specified affiliates of the firm?
_____
_____
Conducted a proceeding or investigation involving the firm, or any predecessors or specified affiliates of the firm?
_____
_____
Issued an order (other than an exemption order) or a sanction to the firm, or any predecessors or specified affiliates of the firm for securities or derivatives-related activity (e.g. cease trade order)?
_____
_____
If yes, provide the following information for each action:
Name of entity
Type of action
Regulator/organization
Date of action (yyyy/mm/dd)
Reason for action
Jurisdiction
7.3 Ongoing investigations
Is the firm aware of any ongoing investigations of which the firm or any of its specified affiliates is the subject?
Yes [ ] No [ ]
If yes, provide the following information for each investigation:
- - - - - - - - - - - - - - - - - - - -
Name of entity
Reason or purpose of investigation
Regulator/organization
Date investigation commenced (yyyy/mm/dd)
Jurisdiction
- - - - - - - - - - - - - - - - - - - -
Part 8 -- Legal action
The firm must disclose offences or legal actions under any statute governing the firm and its business activities in any jurisdiction. The information must be provided in respect of the last 7 years.
8.1 Criminal convictions
Has the firm, or any predecessors or specified affiliates of the firm been convicted of any criminal or quasi-criminal offence?
Yes [ ] No [ ]
If yes, provide the following information for each conviction:
Name of entity
Type of offence
Case name
Case number, if applicable
Date of conviction (yyyy/mm/dd)
Jurisdiction
8.2 Outstanding criminal charges
Is the firm or any of its specified affiliates currently the subject of any outstanding criminal or quasi-criminal charges?
Yes [ ] No [ ]
If yes, provide the following information for each charge:
- - - - - - - - - - - - - - - - - - - -
Name of entity
Type of offence
Date of charge (yyyy/mm/dd)
Jurisdiction
- - - - - - - - - - - - - - - - - - - -
8.3 Outstanding legal actions
|
|
Yes |
No |
|
|
||
|
Is the firm currently a defendant or respondent (or the equivalent in any jurisdiction) in any outstanding legal action? |
_____ |
_____ |
|
|
||
|
Are any of the firm's specified affiliates currently a defendant or respondent (or the equivalent in any jurisdiction) in any outstanding legal action that involves fraud, theft or securities-related activities, or that could significantly affect the firm's business? |
_____ |
_____ |
If yes, provide the following information for each legal action:
- - - - - - - - - - - - - - - - - - - -
Name of entity
Type of legal action
Date of legal action (yyyy/mm/dd)
Current stage of litigation
Remedies requested by plaintiff or appellant
Jurisdiction
- - - - - - - - - - - - - - - - - - - -
8.4 Judgments
|
|
Yes |
No |
|
|
||
|
Has any judgment been rendered against the firm or is any judgment outstanding in any civil court for damages or other relief relating to fraud, theft or securities-related activities? |
_____ |
_____ |
|
|
||
|
Are any of the firm's specified affiliates currently the subject of any judgments that involve fraud, theft or securities-related activities, or that could significantly affect the firm's business? |
_____ |
_____ |
If yes, provide the following information for each judgment:
- - - - - - - - - - - - - - - - - - - -
Name of entity
Type of judgment
Date of judgment (yyyy/mm/dd)
Current stage of litigation, if applicable
Remedies requested by plaintiffs
- - - - - - - - - - - - - - - - - - - -
Part 9 -- Certification[repealed]
It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.
By signing below, you:
1. Certify to the regulator in each jurisdiction of Canada where the firm is submitting and filing this form, either directly or through the principal regulator, that:
• you have read this form, and
• to the best of your knowledge and after reasonable inquiry, all of the information provided on this form is true and complete.
2. Certify to each regulator in a non-principal jurisdiction of Canada where the firm is submitting and filing this form, either directly or through the principal regulator, that at the date of this submission:
• the firm has submitted and filed all information required to be submitted and filed under the securities legislation or derivatives legislation or both of the principal jurisdiction of Canada in relation to the firm's registration in that jurisdiction, and
• this information is true and complete.
3. Authorize the principal regulator to give each non-principal regulator access to any information the firm has submitted or filed with the principal regulator under securities legislation or derivatives legislation or both of the principal jurisdiction of Canada in relation to the firm's registration in that jurisdiction.
4. Acknowledge that the regulator may collect and provide personal information about the individuals referred to in this form under Collection and use of personal information.
5. Confirm that the individuals referred to in this form have been notified that their personal information is disclosed on this form, the legal reason for doing so, how it will be used and who to contact for more information.
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Name of firm
Name of firm's authorized signing officer or partner
Title of firm's authorized signing officer or partner
Signature Date (yyyy/mm/dd)
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The witness must be a lawyer, notary public or commissioner of oaths.
Witness
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Name of witness
Title of witness
Signature
Date (yyyy/mm/dd)
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Schedule A Contact information for notice of collection and use of personal information
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Alberta |
Nunavut |
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Alberta Securities Commission, |
Government of Nunavut |
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Suite 600, 250-5th St. SW |
Department of Justice |
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Calgary, AB T2P 0R4 |
P.O. Box 1000 Station 570 |
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Attention: Information Officer |
Iqaluit, NU X0A 0H0 |
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Telephone: (403) 297-6454 |
Attention: Deputy Registrar of Securities |
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Telephone: (867) 975-6590 |
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British Columbia |
Ontario |
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British Columbia Securities Commission |
Ontario Securities Commission |
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P.O. Box 10142, Pacific Centre |
22nd Floor |
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701 West Georgia Street |
20 Queen Street West |
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Vancouver, BC V7Y 1L2 |
Toronto, ON M5H 3S8 |
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Attention: |
Attention: Compliance and Registrant Regulation |
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Telephone: (604) 899-6500 or (800) 373-6393 (in Canada) |
Telephone: (416) 593-8314 |
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E-mail: [email protected] |
E-mail: [email protected] |
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Manitoba |
Prince Edward Island |
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The Manitoba Securities Commission |
Securities Office |
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500 -- 400 St. Mary Avenue |
Department of Community Affairs and Attorney |
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Winnipeg, MB R3C 4K5 |
P.O. Box 2000 |
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Attention: Director of Registrations |
Charlottetown, PE C1A 7N8 |
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Telephone: (204) 945-2548 |
Attention: Deputy Registrar of Securities |
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Fax (204) 945-0330 |
Telephone: (902) 368-6288 |
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New Brunswick |
Québec |
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Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick |
Autorité des marchés financiers |
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Suite 300, 85 Charlotte Street |
800, square Victoria, 22e étage |
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Saint John, NB E2L 2J2 |
C.P. 246, tour de la Bourse |
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Attention: Director of Securities |
Montréal (Québec) H4Z 1G3 |
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Telephone: (506) 658-3060 |
Attention: Responsable de l'accès à l'information |
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Telephone: (514) 395-0337 or (877) 525-0337 |
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Newfoundland and Labrador |
Saskatchewan |
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Superintendent of Securities, Service NL |
Financial and Consumer Affairs Authority of Saskatchewan |
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Government of Newfoundland and Labrador |
Suite 601, 1919 Saskatchewan Drive |
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P.O. Box 8700 |
Regina, SK S4P 4H2 |
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2nd Floor, West Block |
Attention: |
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Confederation Building |
Telephone: (306) 787-5871 |
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St. John's, NL A1B 4J6 |
E-mail: [email protected] |
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Attention: Manager of Registrations |
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Telephone: (709) 729-5661 |
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Nova Scotia |
Yukon |
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Nova Scotia Securities Commission |
Government of Yukon |
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Suite 400, 5251 Duke Street |
Office of the Yukon Superintendent of Securities |
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Halifax, NS B3J 1P3 |
Department of Community Services |
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Attention: |
P.O. Box 2703 C-6 |
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Telephone: (902) 424-7768 |
Whitehorse, YT Y1A 2C6 |
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Attention: Superintendent of Securities |
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Telephone: |
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Northwest Territories |
Self-regulatory organization |
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Government of the Northwest Territories |
Investment Industry Regulatory Organization of Canada |
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Department of Justice |
121 King Street West, Suite 2000 |
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1st Floor Stuart M. Hodgson Building |
Toronto, Ontario M5H 3T9 |
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5009 -- 49th Street |
Attention: Privacy Officer |
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Yellowknife, NWT X1A 2L9 |
Telephone: (416) 364-6133 |
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Attention: |
E-mail: [email protected] |
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Telephone: (867) 920-8984 |
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Schedule B Submission to jurisdiction and appointment of agent for service
1. Name of person or company (the "Firm"): ____________________
2. Jurisdiction of incorporation of the person or company: ____________________
3. Name of agent for service of process (the "Agent for Service"): ____________________
4. Address for service of process on the Agent for Service: ____________________
______________________________
______________________________
Phone number of the Agent for Service: ____________________
5. The Firm designates and appoints the Agent for Service at the address stated above as its agent upon whom may be served a notice, pleading, subpoena, summons or other process in any action, investigation or administrative, criminal, quasi-criminal or other proceeding (a "Proceeding") arising out of or relating to or concerning the Firm's activities in the local jurisdiction and irrevocably waives any right to raise as a defense in any such proceeding any alleged lack of jurisdiction to bring such Proceeding.
6. The Firm irrevocably and unconditionally submits to the non-exclusive jurisdiction of the judicial, quasi-judicial and administrative tribunals of the local jurisdiction and any administrative proceeding in the local jurisdiction, in any proceeding arising out of or related to or concerning the Firm's activities in the local jurisdiction.
7. Until six years after the Firm ceases to be registered, the Firm must file
a. a new Submission to jurisdiction and appointment of agent for service in this form no later than the 10th day after the date this Submission to jurisdiction and appointment of agent for service is terminated; and
b. an amended Submission to jurisdiction and appointment of agent for service no later than the 10th day after any change in the name or above address of the Agent for Service.
7. Until six years after the Firm ceases to be registered, the Firm must file a new executed Submission to jurisdiction and appointment of agent for service in this form
a. no later than the 15th day after the date this Submission to jurisdiction and appointment of agent for service is terminated, and
b. no later than the 15th day after any change in the name or address of the Agent for Service.
8. This Submission to jurisdiction and appointment of agent for service is governed by and construed in accordance with the laws of the local jurisdiction.
Dated: ____________________________________
______________________________
(Signature of the Firm or authorized signatory)
______________________________
(Name and Title of authorized signatory)
Acceptance
The undersigned accepts the appointment as Agent for Service of (Insert name of the Firm) under the terms and conditions of the foregoing Submission to jurisdiction and appointment of agent for service.
Dated: ____________________________________
______________________________
(Signature of Agent for Service or authorized signatory)
______________________________
(Name and Title of authorized signatory)
Schedule C FORM 31-103F1 CALCULATION OF EXCESS WORKING CAPITAL
______________________________
Firm Name
Capital Calculation
(as at ________________ with comparative figures as at ______________)
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Component |
Current period |
Prior period |
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1. |
Current assets |
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2. |
Less current assets not readily convertible into cash (e.g., prepaid expenses) |
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3. |
Adjusted current assets |
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Line 1 minus line 2 = |
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4. |
Current liabilities |
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5. |
Add 100% of non-current related party debt unless the firm and the lender have executed a subordination agreement in the form set out in Appendix B of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations and the firm has delivered a copy of the agreement to the regulator or, in Québec, the securities regulatory authority. See section 12.2 of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations. |
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6. |
Adjusted current liabilities |
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Line 4 plus line 5 = |
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7. |
Adjusted working capital |
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Line 3 minus line 6 = |
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8. |
Less minimum capital |
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9. |
Less market risk |
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10. |
Less any deductible under the bonding or insurance policy required under Part 12 of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations |
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11. |
Less Guarantees |
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12. |
Less unresolved differences |
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13. |
Excess working capital |
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Notes:
Form 31-103F1 Calculation of Excess Working Capital must be prepared using the accounting principles that you use to prepare your financial statements in accordance with National Instrument 52-107 Acceptable Accounting Principles and Auditing Standards. Section 12.1 of Companion Policy 31-103CP Registration Requirements, Exemptions and Ongoing Registrant Obligations provides further guidance in respect of these accounting principles.
Line 5. Related-party debt -- Refer to the CICA Handbook CPA Canada Handbook for the definition of "related party" for publicly accountable enterprises. The firm is required to deliver a copy of the executed subordination agreement to the regulator or, in Québec, the securities regulatory authority on the earlier of a) 10 days after the date the agreement is executed or b) the date an amount subordinated by the agreement is excluded from its calculation of excess working capital on Form 31-103F1 Calculation of Excess Working Capital. The firm must notify the regulator or, in Québec, the securities regulatory authority, 10 days before it repays the loan (in whole or in part), or terminates the subordination agreement. See section 12.2 of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations.
Line 8. Minimum Capital -- The amount on this line must be not less than (a) $25,000 for an adviser and (b) $50,000 for a dealer. For an investment fund manager, the amount must be not less than $100,000 unless subsection 12.1(4) of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations applies.
Line 9. Market Risk -- The amount on this line must be calculated according to the instructions set out in Schedule 1 to Form 31-103F1 Calculation of Excess Working Capital. A schedule supporting the calculation of any amounts included in Line 9 as market risk should be provided to the regulator or, in Québec, the securities regulatory authority in conjunction with the submission of Form 31-103F1 Calculation of Excess Working Capital.
Line 11. Guarantees -- If the registered firm is guaranteeing the liability of another party, the total amount of the guarantee must be included in the capital calculation. If the amount of a guarantee is included in the firm's statement of financial position as a current liability and is reflected in line 4, do not include the amount of the guarantee on line 11.
Line 12. Unresolved differences -- Any unresolved differences that could result in a loss from either firm or client assets must be included in the capital calculation. The examples below provide guidance as to how to calculate unresolved differences:
(i) If there is an unresolved difference relating to client securities, the amount to be reported on Line 12 will be equal to the fair value of the client securities that are short, plus the applicable margin rate for those securities.
(ii) If there is an unresolved difference relating to the registrant's investments, the amount to be reported on Line 12 will be equal to the fair value of the investments (securities) that are short.
(iii) If there is an unresolved difference relating to cash, the amount to be reported on Line 12 will be equal to the amount of the shortfall in cash.
Please refer to section 12.1 of Companion Policy 31-103CP Registration Requirements, Exemptions and Ongoing Registrant Obligations for further guidance on how to prepare and file Form 31-103F1 Calculation of Excess Working Capital.
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Management Certification
Registered Firm Name: ___________________________________________
We have examined the attached capital calculation and certify that the firm is in compliance with the capital requirements as at
____________________
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Name and Title |
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Signature |
Date |
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1.__________ |
__________ |
__________ |
__________ |
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2.__________ |
__________ |
__________ |
__________ |
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Schedule 1 of Form 31-103F1 Calculation of Excess Working Capital (calculating line 9 [market risk])
For purposes of completing this form:
(1) "Fair value" means the value of a security determined in accordance with Canadian GAAP applicable to publicly accountable enterprises.
(2) For each security whose value is included in line 1, Current Assets, multiply the fair value of the security by the margin rate for that security set out below. Add up the resulting amounts for all of the securities you hold. The total is the "market risk" to be entered on line 9.
(a) Bonds, Debentures, Treasury Bills and Notes
(i) Bonds, debentures, treasury bills and other securities of or guaranteed by the Government of Canada, of the United Kingdom, of the United States of America or of any other national foreign government (provided those foreign government securities have a current credit rating described in subparagraph (i.1)) maturing (or called for redemption):
within 1 year:
1% of fair value multiplied by the fraction determined by dividing the number of days to maturing by 365
over 1 year to 3 years:
1% of fair value
over 3 years to 7 years:
2% of fair value
over 7 years to 11 years:
4% of fair value
over 11 years:
4% of fair value
(i.1) A credit rating from a designated rating organization listed below, from a DRO affiliate of an organization listed below, from a designated rating organization that is a successor credit rating organization of an organization listed below or from a DRO affiliate of such successor credit rating organization, that is the same as one of the following corresponding rating categories or that is the same as a category that replaces one of the following corresponding rating categories:
Designated Rating Organization
Long Term Debt
Short Term Debt
DBRS Limited
AAA
R-1(high)
Fitch Ratings, Inc.
AAA
F1+
Moody's Canada Inc.
Aaa
Prime-1
S&P Global Ratings Canada
AAA
A-1+
(ii) Bonds, debentures, treasury bills and other securities of or guaranteed by any jurisdiction of Canada and obligations of the International Bank for Reconstruction and Development, maturing (or called for redemption):
within 1 year:
2% of fair value multiplied by the fraction determined by dividing the number of days to maturity by 365
over 1 year to 3 years:
3% of fair value
over 3 years to 7 years:
4% of fair value
over 7 years to 11 years:
5% of fair value
over 11 years:
5% of fair value
(iii) Bonds, debentures or notes (not in default) of or guaranteed by any municipal corporation in Canada or the United Kingdom maturing:
within 1 year:
3% of fair value multiplied by the fraction determined by dividing the number of days to maturity by 365
over 1 year to 3 years:
5% of fair value
over 3 years to 7 years:
5% of fair value
over 7 years to 11 years:
5% of fair value
over 11 years:
5% of fair value
(iv) Other non-commercial bonds and debentures (not in default): 10% of fair value
(v) Commercial and corporate bonds, debentures and notes (not in default) and non-negotiable and non-transferable trust company and mortgage loan company obligations registered in the registered firm's name maturing:
within 1 year:
3% of fair value
over 1 year to 3 years:
6% of fair value
over 3 years to 7 years:
7% of fair value
over 7 years to 11 years:
10% of fair value
over 11 years:
10% of fair value
(b) Bank Paper
Deposit certificates, promissory notes or debentures issued by a Canadian chartered bank (and of Canadian chartered bank acceptances) maturing:
within 1 year:
2% of fair value multiplied by the fraction determined by dividing the number of days to maturity by 365
over 1 year:
apply rates for commercial and corporate bonds, debentures and notes
(c) Acceptable foreign bank paper
Deposit certificates, promissory notes or debentures issued by a foreign bank, readily negotiable and transferable and maturing:
within 1 year:
2% of fair value multiplied by the fraction determined by dividing the number of days to maturity by 365
over 1 year:
apply rates for commercial and corporate bonds, debentures and notes
"Acceptable Foreign Bank Paper" consists of deposit certificates or promissory notes issued by a bank other than a Canadian chartered bank with a net worth (i.e., capital plus reserves) of not less than $200,000,000.
(d) Mutual Funds
Securities of mutual funds qualified by prospectus for sale in any jurisdiction of Canada:
(i) 5% of the net asset value per security as determined in accordance with National Instrument 81-106 Investment Fund Continuous Disclosure, where the fund is a money market mutual fund as defined in National Instrument 81-102 Investment Funds; or
(ii) the margin rate determined on the same basis as for listed stocks multiplied by the net asset value per security of the fund as determined in accordance with National Instrument 81-106 Investment Fund Continuous Disclosure.
Securities of mutual funds qualified by prospectus for sale in the United States of America: 5% of the net asset value per security if the fund is registered as an investment company under the Investment Companies Act of 1940, as amended from time to time, and complies with Rule 2a-7 thereof.
(e) Stocks
In this paragraph, "securities" includes rights and warrants and does not include bonds and debentures.
(i) On securities including investment fund securities, rights and warrants, listed on any exchange in Canada or the United States of America:
Long Positions -- Margin Required
Securities selling at $2.00 or more -- 50% of fair value
Securities selling at $1.75 to $1.99 -- 60% of fair value
Securities selling at $1.50 to $1.74 -- 80% of fair value
Securities selling under $1.50 -- 100% of fair value
Short Positions -- Credit Required
Securities selling at $2.00 or more -- 150% of fair value
Securities selling at $1.50 to $1.99 -- $3.00 per share
Securities selling at $0.25 to $1.49 -- 200% of fair value
Securities selling at less than $0.25 -- fair value plus $0.25 per share
(ii) For positions in securities that are constituent securities on a major broadly-based index of one of the following exchanges, 50% of the fair value:
(a) Australian Stock Exchange Limited
(b) Bolsa de Madrid
(c) Borsa Italiana
(d) Copenhagen Stock Exchange
(e) Euronext Amsterdam
(f) Euronext Brussels
(g) Euronext Paris S.A.
(h) Frankfurt Stock Exchange
(i) London Stock Exchange
(j) New Zealand Exchange Limited
(k) Stockholm Stock Exchange
(l) SIX Swiss Exchange
(m) The Stock Exchange of Hong Kong Limited
(n) Tokyo Stock Exchange
(f) Mortgages
(i) For a firm registered in any jurisdiction of Canada except Ontario:
(a) Insured mortgages (not in default): 6% of fair value
(b) Mortgages which are not insured (not in default): 12% of fair value
(ii) For a firm registered in Ontario:
(a) Mortgages insured under the National Housing Act (Canada) (not in default): 6% of fair value
(b) Conventional first mortgages (not in default): 12% of fair value
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If you are registered in Ontario regardless of whether you are also registered in another jurisdiction of Canada, you will need to apply the margin rates set forth in (ii) above.
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(g) For all other securities -- 100% of fair value.
FORM 33-109F7 REINSTATEMENT OF REGISTERED INDIVIDUALS AND PERMITTED INDIVIDUALS (sections 2.3 and 2.4(2))
WARNING -- It is an offence to knowingly give false or misleading information to the regulator or the securities regulatory authority.
CERTIFICATION
Individual
I, the individual, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where I am submitting this form and to any applicable self-regulatory organization (SRO) that
• I have read this form and understand all matters within this form, including the questions and, for greater certainty, if the business location is a residence, the notice in Item 5,
• I have discussed this form with a branch manager, supervisor, officer or partner of my sponsoring firm and that to the best of my knowledge, the branch manager, supervisor, officer or partner is satisfied that I understand all matters within this form, including the questions,
• to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete,
• if applicable, I will limit my activities to those allowed by my category of registration and any SRO approval, and
• the new sponsoring firm understands that if my registration was subject to any terms and conditions that were unsatisfied when I left my former sponsoring firm, those terms and conditions remain in effect and the new sponsoring firm agrees to assume any ongoing obligations that applied to the former sponsoring firm in respect of my registration under those terms and conditions.
I consent to and authorize the collection, directly and indirectly, of personal information by each regulator, securities regulatory authority and SRO and to the use of my personal information as set out in Item 10.
Firm
I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm is submitting this form and to any applicable SRO that
• the individual identified in this form will be engaged by the new sponsoring firm as a registered individual or a permitted individual,
• I have, or a branch manager, supervisor, officer or partner has, discussed this form with the individual. To the best of my knowledge, the individual understands all matters within this form, including the questions, and
• the new sponsoring firm understands that if the individual's registration was subject to any undischarged terms and conditions when the individual left the individual's former sponsoring firm, those terms and conditions remain in effect and agrees to assume any ongoing obligations that apply to the former sponsoring firm in respect of the individual under those terms and conditions.
NRD format:
[ ] I, the authorized firm representative, am making this submission under authority delegated by the firm and the individual identified in this form. By checking this box, I certify that
(a) the firm provided me with all of the information on this form and makes the firm certification above,
(b) the individual provided the firm with all of the information on this form and makes the individual certification above, and
(c) the individual provided the above consent and authorization for the collection and use of the individual's personal information.
Non-NRD format:
Individual
By signing below, I, the individual, make the above individual certification and provide my consent and authorization for the collection, directly and indirectly, and use of my personal information.
Signature of individual ____________________
Date signed ____________________ (YYYY/MM/DD)
Firm
By signing below, I, on behalf of the firm, make the firm certification above.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
GENERAL INSTRUCTIONS
Complete and submit this form to the relevant regulator(s) or in Québec, the securities regulatory authority, or self-regulatory organization (SRO) if an individual has left a sponsoring firm and is seeking to reinstate their registration in one or more of the same categories or reinstate their same status of permitted individual as before with a sponsoring firm. You only need to complete and submit one form regardless of the number of registration categories or permitted individual statuses you are seeking to be reinstated in.
An individual may reinstate their registration or permitted individual status by submitting this form. This form may only be used if all of the following apply:
1. this form is submitted on or before the 90th day after the cessation date of the individual's employment, partnership or agency relationship with the individual's former sponsoring firm,
2. there have been no changes to the information previously submitted in respect of Items 13 (Regulatory Disclosure), other than changes to Item 13.3(c), 14 (Criminal Disclosure), 15 (Civil Disclosure) and 16 (Financial Disclosure) of the individual's Form 33-109F4 since the individual left their former sponsoring firm, and
3. the individual's employment, partnership or agency relationship with their former sponsoring firm did not end because the individual was asked by the firm to resign, resigned voluntarily or was dismissed, following an allegation against the individual of criminal activity, a breach of securities legislation, or a breach of the rules of an SRO.
If you do not meet all of the above conditions then you must apply for reinstatement by completing on NRD a Form 33-109F4 by making the NRD submission entitled 'Reactivation of Registration'.
GENERAL INSTRUCTIONS
Complete and submit this form to the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-regulatory organization (SRO) if
• an individual has left a sponsoring firm and is seeking to reinstate the individual's registration in one or more of the same categories or reinstate the same status of permitted individual as before with a new sponsoring firm, and
• the new sponsoring firm is registered in the same category of registration in which the individual's former sponsoring firm was registered.
You only need to complete and submit one form regardless of the number of registration categories or permitted individual statuses you are seeking to be reinstated in.
An individual may reinstate the individual's registration or permitted individual status by submitting this form. This form must not be used unless all of the following apply:
1. this form is submitted on or before the 90th day after the cessation date of the individual's employment, partnership or agency relationship with the individual's former sponsoring firm;
2. the information in the individual's Form 33-109F4 was up-to-date as of the cessation date of the individual's employment, partnership or agency relationship with the individual's former sponsoring firm;
3. if this form is submitted on or after June 6, 2023, on the date this form is submitted, the individual's information in the National Registration Database does not state "there is no response to this question" for any item of the individual's Form 33-109F4;
4. there have been no changes to the information previously submitted in respect of the following items of the individual's Form 33-109F4 since the individual left the individual's former sponsoring firm:
• Item 13 (Regulatory disclosure), other than changes to Item 13.3(a);
• Item 14 (Criminal disclosure);
• Item 15 (Civil disclosure);
• Item 16 (Financial disclosure);
5. at the time of cessation with the individual's former sponsoring firm, there were no allegations against the individual, in Canada or in any foreign jurisdiction, relevant to an assessment of whether the individual is not suitable for registration or the registration is objectionable, including, for greater certainty, an allegation against the individual of any of the following:
• a crime;
• a contravention of any statute, regulation, or order of a court or regulatory body;
• a contravention of any rule or bylaw of an SRO, of a professional body, or of a similar organization;
• a failure to meet any standard of conduct of the sponsoring firm or of any professional body.
If you do not meet all of the above conditions, then you must apply for reinstatement by completing on NRD a Form 33-109F4 by making the NRD submission entitled "Reactivation of Registration".
Terms
In this form,
"you", "your" and "individual" means the individual who is seeking to reinstate their registration or their status as permitted individual.
"former sponsoring firm" means the registered firm where you most recently carried out duties as a registered or permitted individual.
"major shareholder" and "shareholder" mean a shareholder who, in total, directly or indirectly owns voting securities carrying 10 per cent or more of the votes carried by all outstanding voting securities.
"new sponsoring firm" means the registered firm where you will begin carrying out duties as a registered or permitted individual when your registration or permitted individual status is reinstated.
Several terms used in this form are defined in the Form 33-109F4 Registration of Individuals and Review of Permitted Individuals that you submitted when you first became registered.
How to submit this form
NRD format
Submit this form at the National Registration Database (NRD) website in NRD format at www.nrd.ca. If you have any questions, contact the compliance, registration or legal department of the new sponsoring firm or a legal adviser with securities law experience, or visit the NRD information website at www.nrd-info.ca.
Format, other than NRD format
If you are relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database, you may submit this form in a format other than NRD format.
If you need more space, use a separate sheet of paper. Clearly identify the Item and question number. Complete and sign the form, and send it to the relevant regulator(s) or, in Québec, the securities regulatory authority, SRO (s) or similar authority. The number of originally signed copies of the form you are required to submit depends on the province or territory, and on the regulator, the securities regulatory authority or SRO.
To avoid delays in processing this form, be sure to answer all of the items that apply to you. If you have questions, contact the compliance, registration or legal department of the new sponsoring firm or a legal adviser with securities law experience, or visit the National Registration Database information website at www.nrd-info.ca.
Item 1 Name
1. NRD number: ____________________
2. Legal name
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__________ |
__________ |
__________ |
__________ |
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Last name |
First name |
Second name (N/A [ ]) |
Third name (N/A [ ]) |
3. Date of birth (YYYY/MM/DD):
4. Use of other names
Are you currently using, or have you ever used, operated under, or carried on business under, a name other than the name(s) mentioned above (for example, trade names for sole proprietorships or team names)?
Yes [ ] No [ ]
If "Yes", complete Schedule A.
Item 2 Number of jurisdictions
1. Are you seeking to reinstate your registration or permitted individual status in more than one jurisdiction of Canada?
Yes [ ] No [ ]
2. Check each province or territory in which you are seeking reinstatement of registration or reinstatement as a permitted individual:
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2. Check each province or territory in which you are seeking reinstatement of registration or, if you are seeking reinstatement as a permitted individual, check each province or territory where your sponsoring firm is registered:
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All jurisdictions |
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Manitoba |
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New Brunswick |
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Nova Scotia |
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Ontario |
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Québec |
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Saskatchewan |
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Yukon |
Item 3 Individual categories
1. On Schedule B, check each category for which you are seeking to reinstate your registration or permitted individual status. If you are seeking reinstatement of status as a permitted individual, check each category that describes your position with your new sponsoring firm.
2. If you are seeking reinstatement as a representative of a mutual fund dealer or of a scholarship plan dealer in Québec, are you covered by your new sponsoring firm's professional liability insurance?
Yes [ ] No [ ]
If "No", state:
The name of your insurer _____________________________________________________
Your policy number _________________________________________________________
Item 4 Address and agent for service
1. Address for service
You must have one address for service in each province or territory where you are submitting this form. A residential or business address is acceptable. A post office box is not acceptable. Complete Schedule C for each additional address for service you are providing.
Address for service:
____________________ (number, street, city, province or territory, postal code)
Telephone number ____________________
Fax number, if applicable ____________________
Business e-mail address ____________________
2. Agent for service
If you have appointed an agent for service, provide the following information for the agent in each province or territory where you have an agent for service. The address of your agent for service must be the same as the address for service above. If your agent for service is not an individual, provide the name of your contact person.
Name of agent for service: ____________________
Contact person: ____________________ Last name, First name
Item 5 Location of employment
1. Provide the following information for your new sponsoring firm. If you will be working out of more than one business location, provide the following information for the business location out of which you will be doing most of your business. If you are only filing this form because you are a permitted individual and are not employed by, or acting as agent for, the sponsoring firm, select "N/A".
Unique Identification Number (optional): ____________________
NRD location number: ____________________
Business location address: ____________________ (number, street, city, province, territory or state, country, postal code)
Telephone number: (___) ____________________ Fax number: (___) ____________________
N/A [ ]
2. If the new sponsoring firm has a foreign head office, and/or you are not a resident of Canada, provide the address for the business location in which you will be conducting most of your business. If you are only filing this form because you are a permitted individual and are not employed by, or acting as agent for, the sponsoring firm, select "N/A".
Business location address: ____________________ (number, street, city, province, territory or state, country, postal code)
Telephone number: (___) ____________________ Fax number: (___) ____________________
N/A [ ]
[The following under #3 "Type of business location", #4 and #5 is for a Format other than NRD format only]
3. Type of business location:
[ ] Head office
[ ] Branch or business location
[ ] Sub-branch (Mutual Fund Dealers Association of Canada members only)
4. Name of supervisor or branch manager: ____________________
5. [ ] Check here if the mailing address of the business location is the same as the business location address provided above. Otherwise, complete the following:
Mailing address: ____________________ (number, street, city, province, territory or state, country, postal code)
6. Notice regarding a business location that is a residence
For the administration of securities legislation or derivatives legislation, including commodity futures legislation, or both, the regulator or, in Québec, the securities regulatory authority may require access to the business location to review the books, records and documents of the registered firm. If applicable, the SRO may also require access to the business location for the administration of the rules of the SRO.
If the business location specified in this form is a residence, the regulator, securities regulatory authority or SRO may request consent to enter the residence.
If consent is not provided, it may affect the ability of the regulator, securities regulatory authority or SRO to access the books, records or documents of a registered firm and to determine whether securities legislation, derivatives legislation (including commodity futures legislation) or the rules of the SRO are being complied with. As a result, the regulator, securities regulatory authority or SRO may take action if it is unable to access and review the books, records or documents of a registered firm held at the business location.
Item 6 Previous employment
Provide the following information for your former sponsoring firm.
Name: ____________________
Date on which you were no longer authorized to act on behalf of your former sponsoring firm as a registered individual or permitted individual: ____________________ (YYYY/MM/DD)
The reason why you left your former sponsoring firm:
______________________________
Item 7 Current employment, other business activities, officer positions held and directorships
Name of your new sponsoring firm: ____________________
Complete a separate Schedule D for each of your current business and employment activities, including employment and business activities with your new sponsoring firm and any employment and business activities outside your new sponsoring firm. Also include all officer or director positions and any other equivalent positions held, as well as positions of influence. The information must be provided
• whether or not you receive compensation for such services, and
• whether or not any such position is business related.
Item 7 Reportable activities
Name of your new sponsoring firm: ____________________
1. Activities with your sponsoring firm
Instructions: Describe all of your roles and responsibilities with your sponsoring firm, whether these roles and responsibilities are securities-related or not (e.g., sale of securities, review of marketing materials, IT help desk, negotiation of employment contracts, sales of banking and insurance products and services). Include any other information about your position with your sponsoring firm that is relevant for the regulator or, in Québec, the securities regulatory authority to know (e.g., if your role is specialized). For example, if you are applying as an advising representative limited to client relationship management, indicate this by including the following statement in Schedule D: "Individual is seeking registration as CRM AR."
Complete a Schedule D with respect to your roles and responsibilities with your sponsoring firm.
2. Reportable outside activities
Instructions: Consider all of the activities that you participate in outside of your sponsoring firm, whether or not you receive compensation for such activities and whether or not any such activity is business-related. Activities performed for an affiliated entity are considered activities outside of your sponsoring firm. If any of the categories below describes one or more activities that you participate in, complete a separate Schedule D for each activity or entity. If multiple activities are performed for one entity, complete a single Schedule D identifying all the activities performed.
Uncompensated activities that do not fall within Categories 1 to 5 (i.e., generally activities that do not involve securities or financial services and are not a position of influence, such as being a little league soccer coach) are not reportable.
Category 1 -- Activities with another registered firm
Instructions: Report activities with registered firms, other than your sponsoring firm. All activities in this category are reportable, whether or not you receive compensation for such activities. Major shareholder means a shareholder who, in total, directly or indirectly owns voting securities carrying 10 percent or more of the votes carried by all outstanding voting securities.
If you are a director, officer, employee, contractor, consultant, agent, or service provider of a registered firm other than your sponsoring firm, or are in any other equivalent position with or for that registered firm, or are a major shareholder or partner of that registered firm, complete a separate Schedule D for the registered firm.
Category 2 -- Activities with an entity that receives compensation from a registered firm
If you are a director, officer, employee, contractor, consultant, or agent of a specified entity, or are in any other equivalent position with or for a specified entity, or are a shareholder or partner of a specified entity, complete a separate Schedule D for the specified entity.
For the purposes of this category, "specified entity" means an entity that receives compensation from a registered firm for activities that you provide for your sponsoring firm or another registered firm.
Category 3 -- Other securities-related activities
Instructions: All activities in this category are reportable, whether or not you receive compensation for such activities. Charitable or other fundraising activities that do not involve the issuance of securities or derivatives are not reportable.
If you have been at any time in the last 7 years directly involved in raising money for an entity through the issuance of securities or derivatives or promoting the sale of an entity's securities or derivatives outside of your activities with your sponsoring firm or another registered firm, complete a separate Schedule D for each entity for which you performed these activities.
Directors and officers of reporting issuers and of entities that have been at any time in the last 7 years raising money through the issuance of securities or derivatives are considered to be directly involved in raising money for that entity.
Category 4 -- Provision of financial or finance-related services
Instructions: All activities in this category are reportable, whether or not you receive compensation for such activities. For example, volunteer activities pertaining to your securities or financial services knowledge must be reported under this category. Also report if you are the owner or management of an entity that provides these services. Major shareholder means a shareholder who, in total, directly or indirectly owns voting securities carrying 10 percent or more of the votes carried by all outstanding voting securities.
Complete a separate Schedule D for each activity, as applicable, if you
• sell or negotiate insurance, including being an insurance broker or agent,
• provide loan or deposit or other banking products and services,
• carry on a money service business, including exchanging one type of currency for another, transferring money from one person to another, or issuing or redeeming money orders, traveller's cheques or anything similar,
• facilitate or administer mortgages, including acting as a mortgage broker, agent or administrator,
• prepare tax returns or provide tax advice,
• help create programs for persons to meet their long-term financial goals, including providing financial planning (including estate planning) or financial advice,
• provide corporate finance services, including services provided in the capacity of a comptroller, treasurer and chief financial officer,
• advise persons under financial stress on credit/debt restructuring,
• are a pension consultant,
• provide advice on mergers and acquisitions,
• provide accounting or bookkeeping services,
• provide oversight or independent review or expert opinion on the management of an entity's financial assets,
• lend money or accept deposits of money (e.g., alternative financing, non-bank financial institutions), or
• provide other financial or finance-related services not identified above.
Also complete a separate Schedule D for each activity, as applicable, if you are a director or officer, or are in any other equivalent position with or for, or are a major shareholder or active partner of, an entity that provides one or more of the services in the above list.
Category 5 -- Positions of influence
Instructions: All positions of influence (e.g., medical doctor, leader in a religious organization) are reportable, whether or not you receive compensation for such activities. Guidance: see also section 13.4.3 of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations and the Companion Policy to National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations.
Complete a separate Schedule D for each position of influence that you are in.
Item 8 Ownership of securities in new sponsoring firm
Are you a partner or major shareholder of your new sponsoring firm?
Yes [ ] No [ ]
If "Yes", complete Schedule E.
Item 9 Confirm permanent record
1. Check the appropriate box to indicate that, since leaving your former sponsoring firm, there has been a change to any information previously submitted for the items of your Form 33-109F4 that are listed below.
[ ] Regulatory disclosure (Item 13, other than changes to Item 13.3(c))
[ ] Criminal disclosure (Item 14)
[ ] Civil disclosure (Item 15)
[ ] Financial disclosure (Item 16)
2. Check the box below -- I am eligible to file this Form 33-109F7, only if you satisfy both of the following conditions:
(a) there are no changes to any of the disclosure items under Item 9.1 above, and
(b) your employment, partnership or agency relationship with your former sponsoring firm did not end because you were asked by the firm to resign or resigned voluntarily, or were dismissed, following an allegation against you of
• criminal activity,
• a breach of securities legislation, or
• a breach of the rules of an SRO.
If you do not meet the above conditions for selecting the box 'I am eligible to file this Form 33-109F7', then you must apply for reinstatement by completing on NRD a Form 33-109F4 by making the NRD submission entitled "Reactivation of Registration". If you are submitting a Form 33-109F4 in a format other than NRD format you must complete the entire form.
[ ] I am eligible to file this Form 33-109F7.
2. Check the box below -- I am eligible to file this Form 33-109F7 - only if you satisfy all of the following conditions:
(a) the information in your Form 33-109F4 was up-to-date when you left your sponsoring firm;
(b) there are no changes to any of the disclosure items under Item 9.1 above;
(c) if this form is submitted on or after June 6, 2023, on the date this form is submitted, your information in the National Registration Database does not state "there is no response to this question" for any item of Form 33-109F4;
(d) at the time of cessation with your former sponsoring firm, there was no allegation against you, in Canada or in any foreign jurisdiction, relevant to an assessment of whether you are not suitable for registration or your proposed registration is objectionable, including, for greater certainty, any allegations against you of
• a crime,
• a contravention of any statute, regulation, or order of a court or regulatory body,
• a contravention of any rule or bylaw of an SRO, or a professional body, or of a similar organization, or
• a failure to meet any standard of conduct of the sponsoring firm or of any professional body.
If you do not meet the above conditions for selecting the box 'I am eligible to file this Form 33-109F7', then you must apply for reinstatement by completing on NRD a Form 33-109F4 by making the NRD submission entitled "Reactivation of Registration". If you are submitting a Form 33-109F4 in a format other than NRD format you must complete the entire form.
[ ] I am eligible to file this Form 33-109F7.
Item 10 Acknowledgements, submission to jurisdiction and notice of collection and use of personal information
By submitting this form, you:
• acknowledge that the submission to jurisdiction, consent to collection and use of personal information, and authorization in respect of SROs (to the extent applicable) that you provided in your Form 33-109F4 remain in effect and extend to this form
• consent to the collection and disclosure of your personal information by regulators and by your sponsoring firm, in each case, for registration and other related regulatory purposes.
If you have any questions about the collection and use of your personal information, contact the securities regulatory authority or applicable SRO in the relevant jurisdiction. See Schedule F for details. In Québec, you can also contact the Commission d'accès à l'information at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca.
You acknowledge and agree that if you are seeking reinstatement of your registration and it was subject to any undischarged terms and conditions when you left your former sponsoring firm, those terms and conditions will remain in effect at your new sponsoring firm.
Item 10 Submission to jurisdiction and notice and consent for collection and use of personal information
1. Submission to jurisdiction
By submitting this form, you agree to be subject to the securities legislation or derivatives legislation (including commodities futures legislation) or both of each jurisdiction of Canada, and to the bylaws, regulations, rules, rulings and policies (collectively referred to as "rules" in this form) of the SROs to which you have submitted this form. This includes the jurisdiction of any tribunals or any proceedings that relate to your activities as a registrant or a partner, director or officer of a registrant under that securities legislation or derivatives legislation or both or as an approved person under SRO rules.
2. Notice of collection and use of personal information
Your personal information is collected by, or on behalf of, each securities regulatory authority and SRO set out in Schedule F. Any of the securities regulatory authorities or SROs set out in Schedule F may contact governmental or regulatory authorities, private bodies or agencies, individuals, corporations, employers, and other organizations, in Canada and in other countries, for information about you.
This personal information is being collected under the authority of the applicable securities legislation, derivatives legislation (including commodity futures legislation) or both of the securities regulatory authorities and under the SRO rules of an SRO set out in Schedule F. The collection, use and disclosure are done in accordance with applicable freedom of information and privacy legislation.
The principal purpose of this collection by the securities regulatory authorities is to administer, enforce, carry out their duties or exercise their powers under their respective securities legislation, derivatives legislation (including commodity futures legislation) or both, and by the SROs to administer and enforce the rules of the SROs.
The information submitted by you in this form with your consent, or collected indirectly with your authorization, may be collected
• at the time of your application,
• at any time during your registration or while you are a permitted individual, or
• at the time the regulator or, in Québec, the securities regulatory authority, or the SRO is informed by your sponsoring firm that you no longer have authority to act on behalf of the sponsoring firm or are not permitted individual of the sponsoring firm.
If you have any questions about the collection, use and disclosure of this information, contact the securities regulatory authority or SRO in any jurisdiction in which the required information is submitted. See Schedule F for details.
Certain information, such as your name(s) (including aliases, trade names or some past names), your sponsoring firm, and other relevant registration information, will be listed in a publicly available registry of registered individuals and, if applicable, on the Disciplined List.
Certain securities regulatory authorities may provide to or receive from certain entities information under separate provisions of their securities legislation or derivatives legislation (including commodity futures legislation) or both, and SROs may provide or receive information under the rules of the SROs. This consent and notice does not limit the authority, powers, obligations or rights conferred on any of the securities regulatory authorities by legislation or regulations in effect in their jurisdiction.
3. Consent to collect and use personal information
By submitting this form, you consent to and authorize the collection, directly and indirectly, of personal information by each securities regulatory authority and SRO and to the use of your personal information as set out above.
The personal information that each securities regulatory authority or SRO collects includes the following:
• the personal information provided in this form;
• the personal information provided by your sponsoring firm;
• registration or financial services licensing information;
• law enforcement records, including police records;
• credit records;
• bankruptcy or other insolvency records;
• employment records and information received from an employer;
• records and information received from entities you had or have an independent contractor or agency relationship with;
• personal information available online;
• records from governmental or regulatory authorities, SROs or professional bodies;
• records of, and used in, court proceedings, including probation records.
Item 11 Warning[repealed]
It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.
Item 12 Certification[repealed]
1. Certification -- NRD format:
I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm. To the best of my knowledge, the officer, branch manager or supervisor was satisfied that I fully understood the questions. I will limit my activities to those permitted by my category of registration. If the business location specified in this form is a residence, I hereby give my consent for the regulator or, in Québec, the securities regulatory authority to enter that residence for the administration of securities legislation and derivatives legislation, including commodity futures legislation.
[ ] I am making this submission as agent for the individual. By checking this box, I certify that the individual provided me with all of the information on this form and the certification above.
2. Certification -- Format other than NRD format:
Individual
By signing below, I certify to the regulator, or in Québec the securities regulatory authority, in each jurisdiction where I am submitting this form, either directly or through the principal regulator that:
• I have read the form and understand the questions,
• all of the information provided on this form is true, and complete, and
• if the business location specified in this form is a residence, I hereby give my consent for the regulator or, in Québec, the securities regulatory authority to enter that residence for the administration of securities legislation and derivatives legislation, including commodity futures legislation.
Signature of individual ____________________ (YYYY/MM/DD)
Authorized partner or officer of the new sponsoring firm
By signing below, I certify to the regulator, or in Québec the securities regulatory authority, in each jurisdiction where I am submitting this form for the individual that:
• the individual will be engaged by the new sponsoring firm as a registered individual or a permitted individual
• I have, or a branch manager or another officer or supervisor has, discussed the questions set out in this form with the individual and, to the best of my knowledge, the individual fully understands the questions, and
• the new sponsoring firm understands that if the individual's reinstatement of registration was subject to any undischarged terms and conditions when the individual left their former sponsoring firm, those terms and conditions remain in effect and agrees to assume any ongoing obligations that apply to the sponsoring firm in respect of the individual under those terms and conditions.
Name of firm ____________________
Name of authorized signing officer or partner ____________________
Title of authorized signing officer or partner ____________________
Signature of authorized signing officer or partner ____________________
Date signed ____________________ (YYYY/MM/DD)
Schedule A Use of other names (Item 1.4)
Item 1.4 Use of other names
Name 1:
Name: ____________________
Provide the reasons for the use of this other name (for example, trade name or team name): ____________________
If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?
Yes [ ] No [ ]
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When did you use this name? |
From: |
To: |
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__________ (YYYY/MM) |
__________ (YYYY/MM) |
Name 2:
Name: ____________________
Provide the reasons for the use of this other name (for example, trade name or team name): ____________________
If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?
Yes [ ] No [ ]
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When did you use this name? |
From: |
To: |
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__________ (YYYY/MM) |
__________ (YYYY/MM) |
Name 3:
Name: ____________________
Provide the reasons for the use of this other name (for example, trade name or team name): ____________________
If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?
Yes [ ] No [ ]
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When did you use this name? |
From: |
To: |
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__________ (YYYY/MM) |
__________ (YYYY/MM) |
Schedule B Individual Categories (Item 3)
Check each category for which you are seeking reinstatement of registration, approval or permitted individual status
Categories Common to all jurisdictions under securities legislation
Firm categories [Format other than NRD format only]
[ ] Investment Dealer
[ ] Mutual Fund Dealer
[ ] Scholarship Plan Dealer
[ ] Exempt Market Dealer
[ ] Restricted Dealer
[ ] Portfolio Manager
[ ] Restricted Portfolio Manager
[ ] Investment Fund Manager
Individual categories and permitted activities
[ ] Dealing Representative
[ ] Advising Representative
[ ] Associate Advising Representative
[ ] Ultimate Designated Person
[ ] Chief Compliance Officer
[ ] Permitted Individual
[ ] Officer -- Specify title:
[ ] Director
[ ] Partner
[ ] Shareholder
[ ] Branch Manager (MFDA members only)
[ ] IIROC approval only
IIROC
Approval categories
[ ] Executive
[ ] Director (Industry)
[ ] Director (Non-Industry)
[ ] Supervisor
[ ] Investor
[ ] Registered Representative
[ ] Investment Representative
[ ] Trader
[ ] Executive
[ ] Director (Industry)
[ ] Director (Non-Industry)
[ ] Supervisor
[ ] Investor
[ ] Registered Representative
[ ] Investment Representative
[ ] Portfolio Manager
[ ] Associate Portfolio Manager
[ ] Trader
Additional approval categories
[ ] Chief Compliance Officer
[ ] Chief Financial Officer
[ ] Ultimate Designated Person
Products
[ ] Non-Trading
[ ] Securities
[ ] Options
[ ] Futures Contracts and Futures Contract Options
[ ] Mutual Funds only
Customer type
[ ] Retail
[ ] Institutional
[ ] Not Applicable
Portfolio management
[ ] Portfolio Management
Categories under local commodity futures and derivatives legislation
Ontario
Firm categories
[ ] Commodity Trading Adviser
[ ] Commodity Trading Counsel
[ ] Commodity Trading Manager
[ ] Futures Commission Merchant
Individual categories and permitted activities
[ ] Advising Representative
[ ] Salesperson
[ ] Branch Manager
[ ] Officer -- Specify title:
[ ] Director
[ ] Partner
[ ] Shareholder
[ ] IIROC approval only
Manitoba
Firm categories
[ ] Dealer (Merchant)
[ ] Dealer (Futures Commission Merchant)
[ ] Dealer (Floor Broker)
[ ] Adviser
[ ] Local
Individual categories and permitted activities
[ ] Floor Broker
[ ] Salesperson
[ ] Branch Manager
[ ] Adviser
[ ] Officer -- Specify title
[ ] Director
[ ] Partner
[ ] Futures Contracts Portfolio Manager
[ ] Associate Futures Contracts Portfolio Manager
[ ] IIROC approval only
[ ] Local
Québec
Firm categories
[ ] Derivatives Dealers
[ ] Derivatives Portfolio Manager
Individual categories and permitted activities
[ ] Derivatives Dealing Representative
[ ] Derivatives Advising Representative
[ ] Derivatives Associate Advising Representative
Schedule C Address and agent for service (Item 4)
Item 4.1 Address for service
You must have one address for service in each province or territory in which you are now, or are seeking to become, a registered individual or permitted individual. A post office box is not an acceptable address for service.
Address for service:
____________________ (number, street, city, province or territory, postal code)
Telephone number: (___) ____________________ Fax number: (___) ____________________
Business e-mail address: ____________________
Item 4.2 Agent for service
If you have appointed an agent for service, provide the following information for the agent. The address for service provided above must be the address of the agent named below.
Name of agent for service: ____________________ (if applicable)
Contact person:
____________________ Last name, First name
Schedule D Current employment, other business activities, officer positions held and directorships (Item 7)
Complete a separate Schedule D for each of your current business and employment activities, including employment and business activities with your new sponsoring firm and any employment and business activities outside your new sponsoring firm. Also include all officer or director positions and any other equivalent positions held, as well as positions of influence. The information must be provided
• whether you receive compensation for such services, and
• whether or not such position is business related.
1. Start date
____________________ (YYYY/MM/DD)
2. Firm information
[ ] Check here if this activity is employment with your sponsoring firm.
If the activity is with your sponsoring firm, you are not required to indicate the firm name and address information below:
Name of business or employer: ____________________
______________________________
Address of business or employer:
____________________ (number, street, city, province, territory or state, country)
Name and title of your immediate supervisor: ____________________________________
3. Description of duties
Describe all employment and business activities related to this employer. Include the nature of the business and your duties, title or relationship with the business. If you are seeking registration that requires specific experience, include details such as level of responsibility, value of accounts under direct supervision, number of years of experience, and percentage of time spent on each activity.
______________________________
4. Number of work hours per week
How many hours per week do you devote to this business or employment? ________
If this activity is employment with your sponsoring firm and you work less than 30 hours per week, explain why.
______________________________
5. Conflict of Interest
If you have more than one employer or are engaged in business related activities:
A. Disclose any potential for confusion by clients and any potential for conflicts of interest arising from your multiple employment or business related activities or proposed business related activities.
______________________________
______________________________
______________________________
B. Indicate whether or not any of your employers or organizations where you engage in business related activities are listed on an exchange.
______________________________
______________________________
______________________________
C. Confirm whether the firm has procedures for minimizing potential conflicts of interest and if so, confirm that you are aware of these procedures.
______________________________
______________________________
______________________________
D. State the name of the person at your sponsoring firm who has reviewed and approved your multiple employment or business related activities or proposed business related activities.
______________________________
______________________________
______________________________
E. If you do not perceive any conflicts of interest arising from this employment, explain why.
______________________________
______________________________
______________________________
Schedule D Reportable activities (Item 7)
1. Start date ____________________ (YYYY/MM/DD)
2. Sponsoring firm or other entity information
[ ] Check here if the reportable activity is with your sponsoring firm.
If the reportable activity is with your sponsoring firm, you are not required to indicate the firm's name and address but are required to provide the name and title of your immediate supervisor. For all other types of reportable activity, enter all of the information below:
Name of business or employer: ____________________
Address of business or employer: ____________________ (number, street, city, province, territory or state, country)
Name and title of your immediate supervisor: ____________________
3. Description of the reportable activity and your roles and responsibilities
Instructions: If you are completing this schedule in relation to your activities with your sponsoring firm, for (e) below, provide the title(s) you will use once registered, and if you are already registered, provide the title(s) you use as of the date of this filing.
(a) Describe the entity that you carry on the activity with or for, including the nature of the entity's business.
(b) Is the entity listed on an exchange?
(c) Describe your relationship with the entity.
(d) Describe all of your roles and responsibilities relating to the activity.
______________________________
(e) Provide all business title(s) and professional designation(s) you use for the activity.
______________________________
4. Number of work hours per week
How many hours per week do you spend on this activity? ____________________
5. Conflicts of interest
Instructions: Complete this section if you have a reportable activity outside your sponsoring firm. Do not complete this section if your reportable activity is solely with your sponsoring firm.
Take into consideration existing and reasonably foreseeable material conflicts of interest and existing and potential client confusion.
(a) Does the activity give rise to any material conflicts of interest between the client and the sponsoring firm or you? Does the activity give rise to client confusion? If no material conflicts of interest or client confusion are expected, explain why.
______________________________
______________________________
______________________________
(b) Describe (i) the material conflicts of interest, and (ii) how these conflicts will be addressed in the best interest of the client.
______________________________
(c) Describe (i) the client confusion, and (ii) how the client confusion will be addressed.
______________________________
______________________________
______________________________
(d) Does your sponsoring firm and the entity have procedures for identifying and addressing material conflicts of interest? If so, confirm you are complying with both sets of procedures.
______________________________
(e) State the name and title of the individual at your sponsoring firm who has reviewed and approved the activity.
______________________________
______________________________
______________________________
Schedule E Ownership of securities in new sponsoring firm (Item 8)
Firm name (whose business is trading in or advising on securities or derivatives, or both):
______________________________
What is your relationship to the firm? Partner Major shareholder
What is the period of this relationship?
|
From: |
To: |
(if applicable) |
|
|
||
|
__________ (YYYY/MM) |
__________ (YYYY/MM) |
|
Provide the following information:
a) State the number, value, class and percentage of securities, or the amount of partnership interest you own or propose to acquire when you are reinstated or approved as a result of the review of this form. If acquiring shares when you are so approved or registered, state the source (for example, treasury shares, or if upon transfer, state name of transferor).
______________________________
b) State the market value (approximate, if necessary) of any subordinated debentures or bonds of the firm to be held by you or any other subordinated loan to be made by you to the firm:
______________________________
c) If another person or firm has provided you with funds to invest in the firm, provide the name of the person or firm and state the relationship between you and that person or firm:
______________________________
d) Are the funds to be invested (or proposed to be invested) guaranteed directly or indirectly by any person or firm?
Yes [ ] No [ ]
If "Yes", provide the name of the person or firm and state the relationship between you and that person or firm:
______________________________
e) Have you directly or indirectly given up any rights relating to these securities or this partnership interest, or do you, when you are registered or approved as a result of the review of this form, intend to give up any of these rights (including by hypothecation, pledging or depositing as collateral the securities or partnership interest with any firm or person)?
Yes [ ] No [ ]
If "Yes", provide the name of the person or firm, state the relationship between you and that person or firm and describe the rights that have been or will be given up: ____________________c) If another person or entity has provided you with funds to invest in the firm, provide the name of the person or entity and state the relationship between you and that person or entity:
______________________________
d) Is the payment of the funds to be invested (or proposed to be invested) guaranteed directly or indirectly by any person or entity?
Yes [ ] No [ ]
If "Yes", provide the name of the person or entity and state the relationship between you and that person or entity:
______________________________
e) Have you directly or indirectly given up any rights relating to these securities or this partnership interest, or do you, when you are registered or approved as a result of the review of this form, intend to give up any of these rights (including by hypothecation, pledging or depositing as collateral the securities or partnership interest with any entity or person)?
Yes [ ] No [ ]
If "Yes", provide the name of the person or entity, state the relationship between you and that person or entity and describe the rights that have been or will be given up:
______________________________
f) Is a person other than you the beneficial owner of the shares, bonds, debentures, partnership units or notes held by you?
Yes [ ] No [ ]
If "Yes", complete (g), (h) and (i).
g) Name of beneficial owner:
__________
__________
__________
__________
Last name
First name
Second name (N/A [ ])
Third name (N/A [ ])
h) Residential address:
____________________ (number, street, city, province, territory or state, country, postal code)
i) Occupation:
______________________________
Schedule F Contact information for Notice of notice and consent for collection and use of personal information
|
Alberta |
Nunavut |
|
Alberta Securities Commission, |
Government of Nunavut |
|
Suite 600, 250-5th St. SW |
Department of Justice |
|
Calgary, AB T2P 0R4 |
P.O. Box 1000 Station 570 |
|
Attention: Information Officer |
Iqaluit, NU X0A 0H0 |
|
Telephone: (403) 297-6454 |
Attention: Deputy Registrar of Securities |
|
Telephone: (867) 975-6590 |
|
|
|
|
|
British Columbia |
Ontario |
|
British Columbia Securities Commission |
Ontario Securities Commission |
|
P.O. Box 10142, Pacific Centre |
22nd Floor |
|
701 West Georgia Street |
20 Queen Street West |
|
Vancouver, BC V7Y 1L2 |
Toronto, ON M5H 3S8 |
|
Attention: |
Attention: Compliance and Registrant Regulation |
|
Telephone: (604) 899-6500 or (800) 373-6393 (in Canada) |
Telephone: (416) 593-8314 |
|
E-mail: [email protected] |
E-mail: [email protected] |
|
|
|
|
Manitoba |
Prince Edward Island |
|
The Manitoba Securities Commission |
Securities Office |
|
500 -- 400 St. Mary Avenue |
Department of Community Affairs and Attorney General |
|
Winnipeg, MB R3C 4K5 |
P.O. Box 2000 |
|
Attention: Director of Registrations |
Charlottetown, PE C1A 7N8 |
|
Telephone: (204) 945-2548 |
Attention: Deputy Registrar of Securities |
|
Fax (204) 945-0330 |
Telephone: (902) 368-6288 |
|
|
|
|
New Brunswick |
Québec |
|
Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick |
Autorité des marchés financiers |
|
Suite 300, 85 Charlotte Street |
800, square Victoria, 22e étage |
|
Saint John, NB E2L 2J2 |
C.P. 246, tour de la Bourse |
|
Attention: Director of Securities |
Montréal (Québec) H4Z 1G3 |
|
Telephone: (506) 658-3060 |
Attention: Responsable de l'accès à l'information |
|
Telephone: (514) 395-0337 or (877) 525-0337 |
|
|
|
|
|
Newfoundland and Labrador |
Saskatchewan |
|
Superintendent of Securities, Service NL |
Financial and Consumer Affairs Authority of Saskatchewan |
|
Government of Newfoundland and Labrador |
Suite 601, 1919 Saskatchewan Drive |
|
P.O. Box 8700 |
Regina, SK S4P 4H2 |
|
2nd Floor, West Block |
Attention: |
|
Confederation Building |
Telephone: (306) 787-5871 |
|
St. John's, NL A1B 4J6 |
E-mail: [email protected] |
|
Attention: Manager of Registrations |
|
|
Telephone: (709) 729-5661 |
|
|
|
|
|
Nova Scotia |
Yukon |
|
Nova Scotia Securities Commission |
Government of Yukon |
|
Suite 400, 5251 Duke Street |
Office of the Yukon Superintendent of Securities |
|
Halifax, NS B3J 1P3 |
Department of Community Services |
|
Attention: |
P.O. Box 2703 C-6 |
|
Telephone: (902) 424-7768 |
Whitehorse, YT Y1A 2C6 |
|
Attention: Superintendent of Securities |
|
|
Telephone: |
|
|
|
|
|
Northwest Territories |
Self-regulatory organization |
|
Government of the Northwest Territories |
Investment Industry Regulatory Organization of Canada |
|
Department of Justice |
121 King Street West, Suite 1600 |
|
1st Floor Stuart M. Hodgson Building |
Toronto, Ontario M5H 3T9 |
|
5009 -- 49th Street |
Attention: Privacy Officer |
|
Yellowknife, NWT X1A 2L9 |
Telephone: (416) 364-6133 |
|
Attention: |
E-mail: [email protected] |
|
Telephone: (867) 920-8984 |
|