FORM 33-109F4 REGISTRATION OF INDIVIDUALS AND REVIEW OF PERMITTED INDIVIDUALS (section 2.2 and 2.5)
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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•
•
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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
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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.
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 other 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;
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“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 ____________________________________________________________________________________________________ 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?
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?
Yes No If “Yes”, complete Schedule A.
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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.
3. 4. 5. 6. 7.
Place of birth _________________________________________________________________________________ (city, province, territory or state, country)
Gender Eye colour Hair colour Height ________ Weight _______
Female
Male
in. or ________ lbs. or _________
cm kg
Item 4 Citizenship 1. Citizenship information What is your country of citizenship? Canada Other, specify: __________________
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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
2.
and you are not currently registered under securities legislation in any jurisdiction of Canada.
Yes
No
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?
Yes No If “No”, state: The name of your insurer__________________________________________________________________________________ Your policy number__________________________________________
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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 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: __________________________________________________________
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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?
Yes No If “Yes”, complete Schedule F. 4. Relevant Securities Experience If you are an individual applying for IIROC approval, select “N/A”. Do you have relevant securities experience? 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)
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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 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
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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.
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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:
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.
2.
3.
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?
Yes No If “Yes”, complete Schedule I, Item 12.1. 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?
Yes No If “Yes”, complete Schedule I, Item 12.2. Committed fraud or the wrongful taking of property, including theft? Yes No 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?
b)
Yes No If “Yes”, complete Schedule J, Item 13.1(a). 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)
d)
2. a)
b)
c)
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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). 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). SRO Regulation 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). 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). 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)?
b)
c)
Yes No If “Yes”, complete Schedule J, Item 13.3(a) Have you ever been refused registration or a licence under any legislation relating to your activities unrelated to securities or derivatives?
Yes No If “Yes”, complete Schedule J, Item 13.3(b). Are you now, or have you ever been, a subject of any disciplinary actions conducted under any legislation relating to your activities unrelated to securities or derivatives?
Yes No If “Yes”, complete Schedule J, Item 13.3(c).
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Item 14 Criminal Disclosure 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
• •
o record suspension has been ordered under the Criminal Records Act (Canada), or o 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, o of which you or any entity when you were a partner, director, officer or major shareholder of that entity has been found guilty, or
o
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.
2.
3.
4.
Are there any outstanding or stayed charges against you alleging a criminal offence that was committed? Yes No If “Yes”, complete Schedule K, Item 14.1. 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?
Yes No If “Yes”, complete Schedule K, Item 14.2. To the best of your knowledge, are there any outstanding or stayed charges against any entity of which you were, at the time the criminal offence was alleged to have taken place, a partner, director, officer or major shareholder?
Yes No If “Yes”, complete Schedule K, Item 14.3. To the best of your knowledge, has any entity, 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?
Yes No If “Yes”, complete Schedule K, Item 14.4.
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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 entity where you are or were a partner, director, officer or major shareholder?
2.
Yes No If “Yes”, complete Schedule L, Item 15.1. Have you or a 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?
Yes No If “Yes”, complete Schedule L, Item 15.2. 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)
b)
c)
d)
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). 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). 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). any proceedings, arrangement or compromise with creditors? Yes No If “Yes”, complete Schedule M, Item 16.1(d).
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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:
Garnishment or seizure in the hands of third persons
Yes
No
Unsatisfied judgment 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
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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 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 of 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 [Repealed]
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Item 22 [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: _________________ (YYYY/MM)
To: _________________ (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: _________________ (YYYY/MM)
To: _________________ (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: _________________ (YYYY/MM)
To: _________________ (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)
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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 live at this address?
From: _________________ (YYYY/MM)
To: _________________ (YYYY/MM)
Address 2: Residential address: ___________________________________________________________________________________ (number, street, city, province, territory or state, country)
When did you live at this address?
From: _________________ (YYYY/MM)
To: _________________ (YYYY/MM)
Address 3: Residential address: ___________________________________________________________________________________ (number, street, city, province, territory or state, country)
When did you live at this address?
From: _________________ (YYYY/MM)
To: _________________ (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 as described in paragraph (c) of the definition of “permitted individual” in section 1.1 of National Instrument 33-109 Registration Information [ ] Officer – Specify title: [ ] Director [ ] Partner [ ] Shareholder [ ] Branch Manager (MFDA members only) [ ] IIROC approval only
IIROC Approval categories [ ] Executive [ ] Director (Industry) [ ] Director (Non-Industry) [ ] Supervisor [ ] Investor [ ] Registered Representative [ ] Investment Representative [ ] 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
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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
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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 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 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.
• •
1. • •
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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.
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
______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
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:
________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________
1. Start date ___________________________ (YYYY/MM/DD)
Schedule G Reportable activities (Item 10)
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.
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______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
(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:
To:
(YYYY/MM)
(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. Reason why you left the firm: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
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 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)
c)
d)
_______________________________________________________________________________________ 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.
_______________________________________________________________________________________ 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.
_______________________________________________________________________________________ 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)
c)
_______________________________________________________________________________________ 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.
_______________________________________________________________________________________ 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, (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)
c)
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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.
_______________________________________________________________________________________ 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.
_______________________________________________________________________________________
Item 14.1
Schedule K Criminal disclosure (Item 14)
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 entity, (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 entity, (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 each plaintiff in the proceeding, (3) whether the proceeding is pending or on appeal, (4) whether the proceeding was against an 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) the name of each plaintiff in the proceeding, (3) the jurisdiction where the action was pursued, (4) whether the proceeding was about an 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 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 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)
(c)
_______________________________________________________________________________________ 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.
_______________________________________________________________________________________ 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 proceeding 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 What is the period of this relationship? From: To: (YYYY/MM) (YYYY/MM)
Major shareholder
(if applicable)
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)
c)
d)
e)
_______________________________________________________________________________________ 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:
_______________________________________________________________________________________ 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:
_______________________________________________________________________________________ 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: _______________________________________________________________________________________ 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)
h)
i)
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Name of beneficial owner: _______________________________________________________________________________________ Last name First name Second name Third name N/A N/A
Residential address: _______________________________________________________________________________________ (number, street, city, province, territory or state, country, postal code)
Occupation: _______________________________________________________________________________________
Schedule O 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: mailto: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 1 st Floor Stuart M. Hodgson Building 5009 – 49 th 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 22 nd 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: mailto: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.ca