FORM 45‑110F4
PORTAL INDIVIDUAL INFORMATION
GENERAL INSTRUCTIONS:
If the funding portal is relying on the start-up crowdfunding registration exemption (section 3 of the Instrument), each founder, director, officer and control person of the funding portal must complete this form and the funding portal must deliver those completed forms and any attachments, along with the corresponding Form 45‑110F3 Funding Portal Information, to the securities regulatory authority or regulator if the funding portal facilitates or intends to facilitate a crowdfunding distribution.
The information provided on this form must be specific to the individual certifying this form.
FUNDING PORTAL INFORMATION
1. Provide the full legal name of the funding portal as it appears on the funding portal’s organizing documents.
2. Provide the name that the funding portal will be operating under.
3. Indicate the position(s) you hold with the funding portal.
INDIVIDUAL INFORMATION
4. Full legal name:
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Middle name(s) |
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Last name |
Yes ☐ No ☐
If yes, provide details.
6. Telephone number and email address:
| Residential: |
( ) |
Mobile: |
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| Business: |
( ) |
Email: |
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7. Provide all residential addresses for the past five years starting with your current residential address.
| Number, street, city, province, territory or state, country and postal/ZIP code |
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8. If you are not a resident of Canada, you must have one address for service of process in Canada and provide the following information:
| Name of agent for service: |
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| Name of contact person: |
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| Address for service: |
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| Telephone: |
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9. Date and place of birth:
| Date of birth |
Place of birth |
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YYYY |
City |
Province/Territory/State |
Country |
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10. Country of citizenship:
Yes ☐ No ☐
If yes, provide your licence or registration type, the securities regulatory authority or regulator, and the start date and ending date, if applicable:
12. Have you ever been dismissed for cause by an employer from a position following allegations that you:
(a) violated any statutes, regulations, rules or standards of conduct,
(b) failed to appropriately supervise compliance with any statutes, regulations, rules or standards of conduct, or
(c) committed fraud or the wrongful taking of property, including, for greater certainty, theft?
Yes ☐ No ☐
If yes, provide all relevant details in an attachment signed and dated by the authorized individual certifying this form that includes the circumstances, relevant dates, names of the parties involved and final disposition, if a final disposition has been made.
CRIMINAL DISCLOSURE
13. Have you ever been found guilty, pleaded no contest to, or been granted an absolute or conditional discharge from
(a) a summary conviction or indictable offence under the Criminal Code,
(b) a quasi-criminal offence in any jurisdiction of Canada or a foreign jurisdiction,
(c) a misdemeanour or felony under the criminal legislation of the United States of America, or any state or territory therein, or
(d) an offence under the criminal legislation of any other foreign jurisdiction?
Yes ☐ No ☐
If yes, provide all relevant details in an attachment signed and dated by the authorized individual certifying this form that includes the circumstances, relevant dates, names of the parties involved and final disposition, if a final disposition has been made.
Instructions: A quasi-criminal offence includes an offence under the Income Tax Act (Canada), the Immigration and Refugee Protection Act (Canada) or the tax, immigration, drugs, firearms, money laundering or securities legislation of any province or territory of Canada or of a foreign jurisdiction.
14. Are there any outstanding or stayed charges against you alleging a criminal offence that was committed?
Yes ☐ No ☐
If yes, provide all relevant details in an attachment signed and dated by the authorized individual certifying this form that includes the circumstances, relevant dates, names of the parties involved and final disposition, if a final disposition has been made.
15. To the best of your knowledge, are there any outstanding or stayed charges against any person or company of which you were, at the time the criminal offence was alleged to have taken place, a founder, director, officer or control person?
Yes ☐ No ☐
If yes, provide all relevant details in an attachment signed and dated by the authorized individual certifying this form that includes the circumstances, relevant dates, names of the parties involved and final disposition, if a final disposition has been made.
16. To the best of your knowledge, has any person or company of which you were a founder, or during the period when you were a director, officer or control person, 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, provide all relevant details in an attachment signed and dated by the authorized individual certifying this form that includes the circumstances, relevant dates, names of the parties involved and final disposition, if a final disposition has been made.
CIVIL DISCLOSURE
Yes ☐ No ☐
If yes, provide all relevant details in an attachment signed and dated by the authorized individual certifying this form that includes the circumstances, relevant dates, names of the parties involved and final disposition, if a final disposition has been made.
18. Are there currently any outstanding civil actions alleging fraud, theft, deceit, misrepresentation, or similar misconduct against you or a person or company of which you are or were a founder, director, officer or control person?
Yes ☐ No ☐
If yes, provide all relevant details in an attachment signed and dated by the authorized individual certifying this form that includes the circumstances, relevant dates, names of the parties involved and final disposition, if a final disposition has been made.
COLLECTION AND USE OF PERSONAL INFORMATION
The personal information required under this form is collected, used and disclosed by the securities regulatory authority or, where applicable, the regulator of the jurisdiction under the authority granted in securities legislation for the purposes of the administration and enforcement of the securities legislation.
By submitting this form, you consent to the collection, use and disclosure of this personal information by the securities regulatory authority or regulator of each jurisdiction in which this form is submitted and any police records, records from other government or non-governmental regulators or self‑regulatory organizations, credit records and employment records about you that the securities regulatory authority or regulator may need to determine the completeness of the information submitted in this form and compliance with the conditions of the start‑up crowdfunding registration and prospectus exemptions. The securities regulatory authority or regulator may contact government and private bodies or agencies, individuals, corporations and other organizations for information about you.
If you have any questions about the collection and use of this information, contact the securities regulatory authority or regulator of any jurisdiction in which this form is submitted. Contact information is listed at the end of this form.
CERTIFICATION
By submitting this form, I
• certify that the statements made in this form, including any attachments, are true and complete, and
• agree to be subject to the securities legislation of each jurisdiction of Canada where I have submitted this form. This includes the jurisdiction of any tribunals or any proceedings that relate to my activities as a founder, director, officer or control person of a funding portal under applicable securities legislation.
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IT IS AN OFFENCE TO MAKE A MISREPRESENTATION IN THIS FORM
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