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
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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.
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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 [Repealed] Item 5 [Repealed] Item 6 [Repealed]
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Schedule A Item 5 [Repealed]