FORM 33-109F7 REINSTATEMENT OF REGISTERED INDIVIDUALS AND PERMITTED INDIVIDUALS (sections 2.3 and 2.5(2))
WARNING - It is an offence to knowingly give false or misleading information to the regulator or the securities regulatory authority.
CERTIFICATION Individual I, the individual, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where I am submitting this form and to any applicable self-regulatory organization (SRO) that
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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 5,
I have discussed this form with a branch manager, supervisor, officer or partner of my sponsoring firm and that to the best of my knowledge, the branch manager, supervisor, officer or partner is satisfied that I understand all matters within this form, including the questions,
to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete,
if applicable, I will limit my activities to those allowed by my category of registration and any SRO approval, and
the new sponsoring firm understands that if my registration was subject to any terms and conditions that were unsatisfied when I left my former sponsoring firm, those terms and conditions remain in effect and the new sponsoring firm agrees to assume any ongoing obligations that applied to the former sponsoring firm in respect of my registration under those terms and conditions.
I consent to and authorize the collection, directly and indirectly, of personal information by each regulator, securities regulatory authority and SRO and to the use of my personal information as set out in Item 10.
Firm I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm is submitting this form and to any applicable SRO that
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the individual identified in this form will be engaged by the new sponsoring firm as a registered individual or a permitted individual,
I have, or a branch manager, supervisor, officer or partner has, discussed this form with the individual. To the best of my knowledge, the individual understands all matters within this form, including the questions, and
the new sponsoring firm understands that if the individual’s registration was subject to any undischarged terms and conditions when the individual left the individual’s former sponsoring firm, those terms and conditions remain in effect and agrees to assume any ongoing obligations that apply to the former sponsoring firm in respect of the individual under those terms and conditions.
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NRD format: I, the authorized firm representative, am making this submission under authority delegated by the firm and the individual identified in this form. By checking this box, I certify that (a) the firm provided me with all of the information on this form and makes the firm certification above, (b) the individual provided the firm with all of the information on this form and makes the individual certification above, and (c) the individual provided the above consent and authorization for the collection and use of the individual’s personal information.
Non-NRD format: Individual By signing below, I, the individual, make the above individual certification and provide my consent and authorization for the collection, directly and indirectly, and use of my personal information.
Signature of individual Date signed (YYYY/MM/DD)
Firm By signing below, I, on behalf of the firm, make the firm certification above. Name of firm Name of authorized signing officer or partner Title of authorized signing officer or partner Signature of authorized signing officer or partner Date signed (YYYY/MM/DD)
GENERAL INSTRUCTIONS Complete and submit this form to the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-regulatory organization (SRO) if • an individual has left a sponsoring firm and is seeking to reinstate the individual’s registration in one or more of the same categories or reinstate the same status of permitted individual as before with a new sponsoring firm, and • the new sponsoring firm is registered in the same category of registration in which the individual’s former sponsoring firm was registered.
You only need to complete and submit one form regardless of the number of registration categories or permitted individual statuses you are seeking to be reinstated in.
An individual may reinstate the individual’s registration or permitted individual status by submitting this form. This form must not be used unless all of the following apply:
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this form is submitted on or before the 90th day after the cessation date of the individual’s employment, partnership or agency relationship with the individual’s former sponsoring firm;
the information in the individual’s Form 33-109F4 was up-to-date as of the cessation date of the individual’s employment, partnership or agency relationship with the individual’s former sponsoring firm;
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if this form is submitted on or after June 6, 2023, on the date this form is submitted, the individual’s information in the National Registration Database does not state “there is no response to this question” for any item of the individual’s Form 33-109F4;
there have been no changes to the information previously submitted in respect of the following items of the individual’s Form 33-109F4 since the individual left the individual’s former sponsoring firm: • Item 13 (Regulatory disclosure), other than changes to Item 13.3(a); • Item 14 (Criminal disclosure); • Item 15 (Civil disclosure); • Item 16 (Financial disclosure);
at the time of cessation with the individual’s former sponsoring firm, there were no allegations against the individual, in Canada or in any foreign jurisdiction, relevant to an assessment of whether the individual is not suitable for registration or the registration is objectionable, including, for greater certainty, an allegation against the individual of any of the following: • a crime; • a contravention of any statute, regulation, or order of a court or regulatory body; • a contravention of any rule or bylaw of an SRO, of a professional body, or of a similar organization; • a failure to meet any standard of conduct of the sponsoring firm or of any professional body.
If you do not meet all of the above conditions, then you must apply for reinstatement by completing on NRD a Form 33-109F4 by making the NRD submission entitled “Reactivation of Registration”.
Terms In this form, “you”, “your” and ”individual” means the individual who is seeking to reinstate their registration or their status as permitted individual.
“former sponsoring firm” means the registered firm where you most recently carried out duties as a registered or permitted individual.
“major shareholder” and “shareholder” mean a shareholder who, in total, directly or indirectly owns voting securities carrying 10 per cent or more of the votes carried by all outstanding voting securities.
“new sponsoring firm” means the registered firm where you will begin carrying out duties as a registered or permitted individual when your registration or permitted individual status is reinstated.
Several terms used in this form are defined in the Form 33-109F4 Registration of Individuals and Review of Permitted Individuals that you submitted when you first became registered.
How to submit this form NRD format Submit this form at the National Registration Database (NRD) website in NRD format at www.nrd.ca. If you have any questions, contact the compliance, registration or legal department of the new sponsoring firm or a legal adviser with securities law experience, or visit the NRD information website at www.nrd-info.ca.
Format, other than NRD format If you are relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database, you may submit this form in a format other than NRD format.
If you need more space, use a separate sheet of paper. Clearly identify the Item and question number. Complete and sign the form, and send it to the relevant regulator(s) or, in Québec, the securities regulatory authority, SRO (s) or similar authority. The number of originally signed copies of the form you are required to submit depends on the province or territory, and on the regulator, the securities regulatory authority or SRO.
To avoid delays in processing this form, be sure to answer all of the items that apply to you. If you have questions, contact the compliance, registration or legal department of the new sponsoring firm or a legal adviser with securities law experience, or visit the National Registration Database information website at www.nrd-info.ca.
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Item 1 Name 1. NRD number: ____________________________________________ 2. Legal name _______________________________________________________________________________________ Last name First name Second name (N/A ) Third name (N/A )
3. Date of birth (YYYY/MM/DD): 4. Use of other names Are you currently using, or have you ever used, operated under, or carried on business under, a name other than the name(s) mentioned above (for example, trade names for sole proprietorships or team names)?
Yes No If “Yes”, complete Schedule A.
Item 2 Number of jurisdictions 1. Are you seeking to reinstate your registration or permitted individual status in more than one jurisdiction of Canada?
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Yes No Check each province or territory in which you are seeking reinstatement of registration or, if you are seeking reinstatement as a permitted individual, check each province or territory where your sponsoring firm is registered:
All jurisdictions
Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon
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Item 3 Individual categories 1. On Schedule B, check each category for which you are seeking to reinstate your registration or permitted individual status. If you are seeking reinstatement of status as a permitted individual, check each category that describes your position with your new sponsoring firm.
2.
If you are seeking reinstatement as a representative of a mutual fund dealer or of a scholarship plan dealer in Québec, are you covered by your new sponsoring firm’s professional liability insurance?
Yes No If “No”, state: The name of your insurer_____________________________________________________ Your policy number_________________________________________________________
Item 4 Address and agent for service 1. Address for service You must have one address for service in each province or territory where you are submitting this form. A residential or business address is acceptable. A post office box is not acceptable. Complete Schedule C for each additional address for service you are providing.
Address for service: _______________________________________________________________________________________ (number, street, city, province or territory, postal code)
Telephone number _________________ Fax number, if applicable____________________ Business e-mail address _____________________________ 2. Agent for service If you have appointed an agent for service, provide the following information for the agent in each province or territory where you have an agent for service. The address of your agent for service must be the same as the address for service above. If your agent for service is not an individual, provide the name of your contact person.
Name of agent for service: ___________________________________________________ Contact person: ____________________________________________________________ Last name, First name
Item 5 Location of employment 1. Provide the following information for your new sponsoring firm. If you will be working out of more than one business location, provide the following information for the business location out of which you will be doing most of your business. If you are only filing this form because you are a permitted individual and are not employed by, or acting as agent for, the sponsoring firm, select “N/A”.
Unique Identification Number (optional): _________________________ NRD location number: _______________________________________ Business location address: ________________________________________________________ (number, street, city, province, territory or state, country, postal code)
Telephone number: ( N/A
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Fax number: (
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If the new sponsoring firm has a foreign head office, and/or you are not a resident of Canada, provide the address for the business location in which you will be conducting most of your business. If you are only filing this form because you are a permitted individual and are not employed by, or acting as agent for, the sponsoring firm, select “N/A”.
Business location address:__ _____________________________________________________________ (number, street, city, province, territory or state, country, postal code)
Telephone number: ( ) Fax number: ( ) N/A [The following under #3 “Type of business location”, #4 and #5 is for a Format other than NRD format only]
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Type of business location: Head office Branch or business location Sub-branch (Mutual Fund Dealers Association members only)
Name of supervisor or branch manager: ______________________________________
Check here if the mailing address of the business location is the same as the business location address provided above. Otherwise, complete the following:
Mailing address: ___________________________________________________________ (number, street, city, province, territory or state, country, postal code)
6. Notice regarding a business location that is a residence For the administration of securities legislation or derivatives legislation, including commodity futures legislation, or both, the regulator or, in Québec, the securities regulatory authority may require access to the business location to review the books, records and documents of the registered firm. If applicable, the SRO may also require access to the business location for the administration of the rules of the SRO.
If the business location specified in this form is a residence, the regulator, securities regulatory authority or SRO may request consent to enter the residence.
If consent is not provided, it may affect the ability of the regulator, securities regulatory authority or SRO to access the books, records or documents of a registered firm and to determine whether securities legislation, derivatives legislation (including commodity futures legislation) or the rules of the SRO are being complied with. As a result, the regulator, securities regulatory authority or SRO may take action if it is unable to access and review the books, records or documents of a registered firm held at the business location.
Item 6 Previous employment Provide the following information for your former sponsoring firm. Name: Date on which you were no longer authorized to act on behalf of your former sponsoring firm as a registered individual or permitted individual: ____________________________________________________________ (YYYY/MM/DD)
The reason why you left your former sponsoring firm: _______________________________________________________________________________________
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Item 7 Reportable activities Name of your new sponsoring firm: ___________________________________________ 1. Activities with your sponsoring firm Instructions: Describe all of your roles and responsibilities with your sponsoring firm, whether these roles and responsibilities are securities-related or not (e.g., sale of securities, review of marketing materials, IT help desk, negotiation of employment contracts, sales of banking and insurance products and services). Include any other information about your position with your sponsoring firm that is relevant for the regulator or, in Québec, the securities regulatory authority to know (e.g., if your role is specialized). For example, if you are applying as an advising representative limited to client relationship management, indicate this by including the following statement in Schedule D: “Individual is seeking registration as CRM AR.”
Complete a Schedule D with respect to your roles and responsibilities with your sponsoring firm. 2. Reportable outside activities Instructions: Consider all of the activities that you participate in outside of your sponsoring firm, whether or not you receive compensation for such activities and whether or not any such activity is business-related. Activities performed for an affiliated entity are considered activities outside of your sponsoring firm. If any of the categories below describes one or more activities that you participate in, complete a separate Schedule D for each activity or entity. If multiple activities are performed for one entity, complete a single Schedule D identifying all the activities performed.
Uncompensated activities that do not fall within Categories 1 to 5 (i.e., generally activities that do not involve securities or financial services and are not a position of influence, such as being a little league soccer coach) are not reportable.
Category 1 - Activities with another registered firm Instructions: Report activities with registered firms, other than your sponsoring firm. All activities in this category are reportable, whether or not you receive compensation for such activities. Major shareholder means a shareholder who, in total, directly or indirectly owns voting securities carrying 10 percent or more of the votes carried by all outstanding voting securities.
If you are a director, officer, employee, contractor, consultant, agent, or service provider of a registered firm other than your sponsoring firm, or are in any other equivalent position with or for that registered firm, or are a major shareholder or partner of that registered firm, complete a separate Schedule D for the registered firm.
Category 2 - Activities with an entity that receives compensation from a registered firm If you are a director, officer, employee, contractor, consultant, or agent of a specified entity, or are in any other equivalent position with or for a specified entity, or are a shareholder or partner of a specified entity, complete a separate Schedule D for the specified entity.
For the purposes of this category, “specified entity” means an entity that receives compensation from a registered firm for activities that you provide for your sponsoring firm or another registered firm.
Category 3 - Other securities-related activities Instructions: All activities in this category are reportable, whether or not you receive compensation for such activities. Charitable or other fundraising activities that do not involve the issuance of securities or derivatives are not reportable.
If you have been at any time in the last 7 years directly involved in raising money for an entity through the issuance of securities or derivatives or promoting the sale of an entity’s securities or derivatives outside of your activities with your sponsoring firm or another registered firm, complete a separate Schedule D for each entity for which you performed these activities.
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Directors and officers of reporting issuers and of entities that have been at any time in the last 7 years raising money through the issuance of securities or derivatives are considered to be directly involved in raising money for that entity.
Category 4 - Provision of financial or finance-related services Instructions: All activities in this category are reportable, whether or not you receive compensation for such activities. For example, volunteer activities pertaining to your securities or financial services knowledge must be reported under this category. Also report if you are the owner or management of an entity that provides these services. Major shareholder means a shareholder who, in total, directly or indirectly owns voting securities carrying 10 percent or more of the votes carried by all outstanding voting securities.
Complete a separate Schedule D for each activity, as applicable, if you • sell or negotiate insurance, including being an insurance broker or agent, • provide loan or deposit or other banking products and services, • carry on a money service business, including exchanging one type of currency for another, transferring money from one person to another, or issuing or redeeming money orders, traveller’s cheques or anything similar, • facilitate or administer mortgages, including acting as a mortgage broker, agent or administrator, • prepare tax returns or provide tax advice, • help create programs for persons to meet their long-term financial goals, including providing financial planning (including estate planning) or financial advice, • provide corporate finance services, including services provided in the capacity of a comptroller, treasurer and chief financial officer, • advise persons under financial stress on credit/debt restructuring, • are a pension consultant, • provide advice on mergers and acquisitions, • provide accounting or bookkeeping services, • provide oversight or independent review or expert opinion on the management of an entity’s financial assets, • lend money or accept deposits of money (e.g., alternative financing, non-bank financial institutions), or • provide other financial or finance-related services not identified above.
Also complete a separate Schedule D for each activity, as applicable, if you are a director or officer, or are in any other equivalent position with or for, or are a major shareholder or active partner of, an entity that provides one or more of the services in the above list.
Category 5 - Positions of influence Instructions: All positions of influence (e.g., medical doctor, leader in a religious organization) are reportable, whether or not you receive compensation for such activities. Guidance: see also section 13.4.3 of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations and the Companion Policy to National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations.
Complete a separate Schedule D for each position of influence that you are in.
Item 8 Ownership of securities in new sponsoring firm Are you a partner or major shareholder of your new sponsoring firm? Yes No If “Yes”, complete Schedule E.
Item 9 Confirm permanent record 1. Check the appropriate box to indicate that, since leaving your former sponsoring firm, there has been a change to any information previously submitted for the items of your Form 33-109F4 that are listed below.
Regulatory disclosure (Item 13), other than changes to Item 13.3(a)
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Criminal disclosure (Item 14) Civil disclosure (Item 15) Financial disclosure (Item 16) Check the box below - I am eligible to file this Form 33-109F7 – only if you satisfy all of the following conditions:
(a) (b) (c)
(d)
the information in your Form 33-109F4 was up-to-date when you left your sponsoring firm; there are no changes to any of the disclosure items under Item 9.1 above; if this form is submitted on or after June 6, 2023, on the date this form is submitted, your information in the National Registration Database does not state “there is no response to this question” for any item of Form 33-109F4;
at the time of cessation with your former sponsoring firm, there was no allegation against you, in Canada or in any foreign jurisdiction, relevant to an assessment of whether you are not suitable for registration or your registration is objectionable, including, for greater certainty, any allegations against you of
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a crime, a contravention of any statute, or regulation, or order of a court or regulatory body, a contravention of any rule or bylaw of an SRO, or a professional body, or of a similar organization, or
a failure to meet any standard of conduct of the sponsoring firm or of any professional body.
If you do not meet the above conditions for selecting the box ‘I am eligible to file this Form 33-109F7’, then you must apply for reinstatement by completing on NRD a Form 33-109F4 by making the NRD submission entitled “Reactivation of Registration”. If you are submitting a Form 33-109F4 in a format other than NRD format you must complete the entire form.
I am eligible to file this Form 33-109F7.
Item 10 Submission to jurisdiction and notice and consent for collection and use of personal information
1. Submission to jurisdiction By submitting this form, you agree to be subject to the securities legislation or derivatives legislation (including commodity futures legislation) or both of each jurisdiction of Canada, and to the bylaws, regulations, rules, rulings and policies (collectively referred to as “rules” in this form) of the SROs to which you have submitted this form. This includes the jurisdiction of any tribunals or any proceedings that relate to your activities as a registrant or a partner, director or officer of a registrant under that securities legislation or derivatives legislation or both or as an approved person under SRO rules.
2. Notice of collection and use of personal information Your personal information is collected by, or on behalf of, each securities regulatory authority and SRO set out in Schedule F. Any of the securities regulatory authorities or SROs set out in Schedule F may contact governmental or regulatory authorities, private bodies or agencies, individuals, corporations, employers, and other organizations, in Canada and in other countries, for information about you.
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This personal information is being collected under the authority of the applicable securities legislation, derivatives legislation (including commodity futures legislation) or both of the securities regulatory authorities and under the SRO rules of an SRO set out in Schedule F. The collection, use and disclosure are done in accordance with applicable freedom of information and privacy legislation.
The principal purpose of this collection by the securities regulatory authorities is to administer, enforce, carry out their duties or exercise their powers under their respective securities legislation, derivatives legislation (including commodity futures legislation) or both, and by the SROs to administer and enforce the rules of the SROs.
The information submitted by you in this form with your consent, or collected indirectly with your authorization, may be collected
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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 F for details.
Certain information, such as your name(s) (including aliases, trade names or some past names), your sponsoring firm, and other relevant registration information, will be listed in a publicly available registry of registered individuals and, if applicable, on the Disciplined List.
Certain securities regulatory authorities may provide to or receive from certain entities information under separate provisions of their securities legislation or derivatives legislation (including commodity futures legislation) or both, and SROs may provide or receive information under the rules of the SROs. This consent and notice does not limit the authority, powers, obligations or rights conferred on any of the securities regulatory authorities by legislation or regulations in effect in their jurisdiction.
3. Consent to collect and use personal information By submitting this form, you consent to and authorize the collection, directly and indirectly, of personal information by each securities regulatory authority and SRO and to the use of your personal information as set out above.
The personal information that each securities regulatory authority or SRO collects includes the following: • the personal information provided in this form; • the personal information provided by your sponsoring firm; • registration or financial services licensing information; • law enforcement records, including police records; • credit records; • bankruptcy or other insolvency records; • employment records and information received from an employer; • records and information received from entities you had or have an independent contractor or agency relationship with; • personal information available online; • records from governmental or regulatory authorities, SROs or professional bodies; • records of, and used in, court proceedings, including probation records.
Item 11 [Repealed]
Item 12 [Repealed]
Schedule A Use of other names (Item 1.4)
Item 1.4 Use of other names Name 1: Name: _________________________________________________________________________________ Provide the reasons for the use of this other name (for example, trade name or team name)?: ____________ If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?
Yes No When did you use this name?
From: _________________ (YYYY/MM)
To: _________________ (YYYY/MM)
Name 2: Name: ________________________________________________________________________________ Provide the reasons for the use of this other name (for example, trade name or team name):
If this other name is or was used in connection with any sponsoring firm, did the sponsoring firm approve the use of the name?
Yes No When did you use this name?
From: _________________ (YYYY/MM)
To: _________________ (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 When did you use this name?
From: _________________ (YYYY/MM)
To: _________________ (YYYY/MM)
Schedule B Individual Categories (Item 3)
Check each category for which you are seeking reinstatement of registration, approval or permitted individual status
Categories Common to all jurisdictions under securities legislation Firm categories [Format other than NRD format only] [ ] Investment Dealer [ ] Mutual Fund Dealer [ ] Scholarship Plan Dealer [ ] Exempt Market Dealer [ ] Restricted Dealer [ ] Portfolio Manager [ ] Restricted Portfolio Manager [ ] Investment Fund Manager
Individual categories and permitted activities [ ] Dealing Representative [ ] Advising Representative [ ] Associate Advising Representative [ ] Ultimate Designated Person [ ] Chief Compliance Officer [ ] Permitted Individual 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
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Products [ ] Non-Trading [ ] Securities [ ] Options [ ] Futures Contracts and Futures Contract Options [ ] Mutual Funds only
Customer type [ ] Retail [ ] Institutional [ ] Not Applicable
Portfolio management [ ] Portfolio Management
Categories under local commodity futures and derivatives legislation Ontario Firm categories [ ] Commodity Trading Adviser [ ] Commodity Trading Counsel [ ] Commodity Trading Manager [ ] Futures Commission Merchant
Individual categories and permitted activities [ ] Advising Representative [ ] Salesperson [ ] Branch Manager [ ] Officer – Specify title: [ ] Director [ ] Partner [ ] Shareholder [ ]IIROC approval only
Manitoba Firm categories [ ] Dealer (Merchant) [ ] Dealer (Futures Commission Merchant) [ ] Dealer (Floor Broker) [ ] Adviser [ ] Local
Individual categories and permitted activities [ ] Floor Broker [ ] Salesperson [ ] Branch Manager [ ] Adviser [ ] Officer – Specify title [ ] Director [ ] Partner [ ] Futures Contracts Portfolio Manager [ ] Associate Futures Contracts Portfolio Manager [ ] IIROC approval only [ ] Local
Québec Firm categories [ ] Derivatives Dealers [ ] Derivatives Portfolio Manager
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Individual categories and permitted activities [ ] Derivatives Dealing Representative [ ] Derivatives Advising Representative [ ] Derivatives Associate Advising Representative
Schedule C Address and agent for service (Item 4)
Item 4.1 Address for service You must have one address for service in each province or territory in which you are now, or are seeking to become, a registered individual or permitted individual. A post office box is not an acceptable address for service.
Address for service: _________________________________________________________________________ (number, street, city, province or territory, postal code)
Telephone number: ( ) Fax number: ( ) Business e-mail address: __________________________ Item 4.2 Agent for service If you have appointed an agent for service, provide the following information for the agent. The address for service provided above must be the address of the agent named below.
Name of agent for service: ___________________________________________________ (if applicable) Contact person: _________________________________________________________________________ Last name, First name
1.
Start date
Schedule D Reportable activities (Item 7)
(YYYY/MM/DD)
2. Sponsoring firm or other entity information Check here if the reportable activity is with your sponsoring firm. If the reportable activity is with your sponsoring firm, you are not required to indicate the firm’s name and address but are required to provide the name and title of your immediate supervisor. For all other types of reportable activity, enter all of the information below:
Name of business or employer: Address of business or employer:
(number, street, city, province, territory or state, country)
Name and title of your immediate supervisor:
3. Description of the reportable activity and your roles and responsibilities Instructions: If you are completing this schedule in relation to your activities with your sponsoring firm, for (e) below, provide the title(s) you will use once registered, and if you are already registered, provide the title(s) you use as of the date of this filing.
(a) (b) (c) (d)
(e)
Describe the entity that you carry on the activity with or for, including the nature of the entity’s business. Is the entity listed on an exchange? Describe your relationship with the entity. Describe all of your roles and responsibilities relating to the activity.
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)
(c)
(d)
(e)
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Describe (i) the material conflicts of interest, and (ii) how these conflicts will be addressed in the best interest of the client.
Describe (i) the client, and (ii) how the client confusion will be addressed.
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.
State the name and title of the individual at your sponsoring firm who has reviewed and approved the activity.
Schedule E Ownership of securities in new sponsoring firm (Item 8)
Firm name (whose business is trading in or advising on securities or derivatives, or both): ___________________________________________________ What is your relationship to the firm? Partner Major shareholder What is the period of this relationship? From: To: (if applicable)
a)
b)
(YYYY/MM) (YYYY/MM) Provide the following information: State the number, value, class and percentage of securities, or the amount of partnership interest you own or propose to acquire when you are reinstated or approved as a result of the review of this form. If acquiring shares when you are so approved or registered, state the source (for example, treasury shares, or if upon transfer, state name of transferor).
_________________________________________________________________________ State the market value (approximate, if necessary) of any subordinated debentures or bonds of the firm to be held by you or any other subordinated loan to be made by you to the firm:
_________________________________________________________________________
c)
d)
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:
e)
_________________________________________________________________________ Have you directly or indirectly given up any rights relating to these securities or this partnership interest, or do you, when you are registered or approved as a result of the review of this form, intend to give up any of these rights (including by hypothecation, pledging or depositing as collateral the securities or partnership interest with any entity or person)?
Yes No If “Yes”, provide the name of the person or entity, state the relationship between you and that person or entity and describe the rights that have been or will be given up:
___________________________________________________
f)
g)
h)
i)
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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). 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 F 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 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: 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