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
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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
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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) (b) (c)
the firm provided me with all of the information on this form and makes the firm certification above, the individual provided the firm with all of the information on this form and makes the individual certification above, and the individual provided the above consent and authorization for the collection and use of the individual’s personal information.
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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.
Firm
Signature of individual Date signed (YYYY/MM/DD)
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
2.
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(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 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 insurer_____________________________________________________________________
your
Your policy number__________________________________________
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3. Relevant securities experience 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 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.
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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.
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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 [Repealed] Item 8 [Repealed]
Schedule A Relevant securities industry 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 and consent for collection and use of personal information
Alberta Alberta Securities Commission Suite 600, 250–5th St. SW Calgary, AB T2P 0R4 Attention: Information Officer Telephone: (403) 297-6454
British Columbia British Columbia Securities Commission P.O. Box 10142, Pacific Centre 701 West Georgia Street Vancouver, BC V7Y 1L2 Attention: Registration staff Telephone: (604) 899-6500 or (800) 373-6393 (in Canada) E-mail: Registration@bcsc.bc.ca
Manitoba The Manitoba Securities Commission 500 - 400 St. Mary Avenue Winnipeg, MB R3C 4K5 Attention: Director of Registrations Telephone: (204) 945-2548 Fax (204) 945-0330
New Brunswick Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick Suite 300, 85 Charlotte Street Saint John, NB E2L 2J2 Attention: Registration Telephone: (506) 658-3060
Newfoundland and Labrador Superintendent of Securities, Service NL Government of Newfoundland and Labrador P.O. Box 8700 2nd Floor, West Block Confederation Building St. John's, NL A1B 4J6 Attention: Manager of Registrations Telephone: (709) 729-5661
Nova Scotia Nova Scotia Securities Commission Suite 400, 5251 Duke Street Halifax, NS B3J 1P3 Attention: Registration Telephone: (902) 424-7768
Northwest Territories Government of the Northwest Territories Department of Justice 1st Floor Stuart M. Hodgson Building 5009 – 49th Street Yellowknife, NWT X1A 2L9 Attention: Superintendent of Securities Telephone: (867) 920-8984
Nunavut Government of Nunavut Department of Justice P.O. Box 1000 Station 570 Iqaluit, NU X0A 0H0 Attention: Superintendent of Securities Telephone: (867) 975-6590
Ontario Ontario Securities Commission 22nd Floor 20 Queen Street West Toronto, ON M5H 3S8 Attention: Compliance and Registrant Regulation Telephone: (416) 593-8314 e-mail: registration@osc.gov.on.ca
Prince Edward Island Securities Office Department of Community Affairs and Attorney General P.O. Box 2000 Charlottetown, PE C1A 7N8 Attention: Superintendent of Securities Telephone: (902) 368-6288
Québec Autorité des marchés financiers 800, square Victoria, 22e étage C.P. 246, tour de la Bourse Montréal (Québec) H4Z 1G3 Attention: Responsable de l’accès à l’information Telephone: (514) 395-0337 or (877) 525-0337
Saskatchewan Financial and Consumer Affairs Authority of Saskatchewan Suite 601, 1919 Saskatchewan Drive Regina, SK S4P 4H2 Attention: Director, Capital Markets Telephone: (306) 787-5871 E-mail: registrationfcaa@gov.sk.ca
Yukon Government of Yukon Office of the Yukon Superintendent of Securities Department of Community Services P.O. Box 2703 C-6 Whitehorse, YT Y1A 2C6 Attention: Superintendent of Securities Telephone: (867) 667-5466
Self-regulatory organization Investment Industry Regulatory Organization of Canada 121 King Street West, Suite 2000 Toronto, Ontario M5H 3T9 Attention: Privacy Officer Telephone: (416) 364-6133 E-mail: PrivacyOfficer@iiroc.c