PROPOSED Form 33-109F4 - Application for Registration of Individuals and Permitted Individuals In this form, “you”, “your” and “applicant” mean the person who is applying for registration or approval as an individual under [the national registration rule]. “Sponsoring firm” means the registered firm where you will carry out your duties as a registered or permitted individual. Several terms used in this form are defined in the securities legislation of your province or territory. Please refer to those local definitions. [Online version] If you have questions, please contact an authorized officer of your sponsoring firm or a legal adviser, or visit the national registration database (NRD) information website at www.nrd-info.ca. [Paper version] Complete this form if you are relying on the temporary hardship exemption in MI 31-102. Otherwise, complete and submit this form online at the national registration database (NRD) website at www.nrd-info.ca. If you need more space, use a separate sheet of paper, clearly identifying the section and item. Please complete and sign the form, and send it to the appropriate Canadian securities regulator(s), self-regulatory organization (SRO) or similar authority. The number of originally signed copies of the form you are required to submit depends on the province or territory, and jurisdiction. Failure to answer all applicable questions may cause delays in the processing of the application form. If you have questions, please contact an authorized officer of your sponsoring firm or a legal adviser, or visit the national registration database (NRD) information website at www.nrdinfo.ca. Item 1 – Name 1. Legal name ________________________________________________________________________ Last Name First Name Second Name (N/A ) Third Name (N/A ) 2. Other personal names Are you currently, or have you ever been, known by any names other than your full legal name above? Yes No
2 If “yes”, complete Schedule A 3. Business names Are you currently, or have you ever used, operated under, or carried on business under any name (e.g., trade names or style names) other than the name(s) mentioned above? Yes No If “yes”, complete Schedule A Item 2 – Residential address Provide all residential addresses, including any foreign residential addresses, for the past 10 years. 1. Current residential address Number, street City, province, territory or state, country, postal code Telephone number: Lived at this address since (YYYY/MM) If you have resided 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 Item 3 – Personal information 1. Date of birth (YYYY/MM/DD) 2. Place of birth City, province, territory or state, country
3 3. Gender Female Male 4. Eye colour 5. Hair colour 6. Height ________ in. ________ cm. 7. Weight _______ lbs. _________ kg. Item 4 – Citizenship Citizenship information What is your citizenship? Canadian Other, specify: If you are a citizen of another country besides Canada, complete the following for that other citizenship: Passport number: Country of citizenship: Date of issue: (YYYY/MM/DD) Place of issue: (city, province, territory or state, country) Item 5 – Registration jurisdictions Indicate, by checking the appropriate box, each province or territory to which you are submitting this form: Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island
4 Québec Saskatchewan Yukon Item 6 – Individual categories Indicate, by checking the appropriate box in Schedule C, each registration category for which you are applying. If you are a permitted individual, indicate each category that describes your position with your sponsoring firm. 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 post office box is not an acceptable address for service. A residential address is acceptable. 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 available E-mail address, if available 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 a firm, also provide the name of your contact person. Name for agent for service: Contact person: Last name, First Name
5 Item 8 - Proficiency 1. Course or examination information Complete Schedule E to indicate each course and examination that you have successfully completed or have been exempted from. Under “Other”, include any post-secondary education and all degrees and diplomas that are relevant to the registration that you are applying for. 2. Student numbers If you have a student number for a course that was successfully completed with one of the following institutions, provide it below: Canadian Securities Institute (CSI): Investment Funds Institute of Canada (IFIC): Institute of Canadian Bankers (ICB): CFA Institute: Canadian Association of Insurance and Financial Advisors (CAIFA): 3. Exemption refusal Has any securities regulatory authority or self-regulatory organization refused to grant you an exemption from a course, examination or experience requirement? Yes No If “Yes”, complete Schedule F. Item 9 – Location of employment Provide the following information for the location of the sponsoring firm at which you will be working. If you will be working out of more than one location, provide the following information for the location out of which you will be doing most of your business. NRD location number: Branch Transit number/Cost Centre Number, if applicable: Business address: (number, street, city, province, territory or state, country, postal code) Telephone number: ( ) Fax number: ( ) [The following is for the paper version only] Type of Location: Head Office Branch Sub-branch Name of Branch Manager: Effective date: Check here if the mailing address of the location is the same as the business address provided above. Otherwise, complete the following:
6 Mailing address: (number, street, city, province, territory or state, country, postal code) Item 10 - Current employment and other business activities Employment information and other business activities On Schedule G, provide the information requested for each of your current business and employment activities, including those with your sponsoring firm and outside of your sponsoring firm. If you are applying for a type of registration that requires specific experience, include details of that experience (for example, level of responsibility, value of accounts under direct supervision, number of years of that experience and research experience, as well as percentage of time spent on each activity). Item 11 - Previous employment Employment information On Schedule H, provide complete employment history for the 10-year period before the date of this application. Item 12 – Resignations and terminations Have you ever resigned, been terminated or discharged by an employer for cause from a position following allegations that you: a) Violated any statutes, regulations, rules or standards of conduct? Yes No If “Yes”, complete Schedule I b) Failed to supervise compliance with any statutes, regulations, rules or standards of conduct? Yes No If “Yes”, complete Schedule I c) Committed fraud or the wrongful taking of property, including theft? Yes No
7 If “Yes”, complete Schedule I Item 13 – Regulatory disclosure In this Form, “derivatives” means financial instruments, such as futures contracts, 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. “Major shareholder” means a shareholder who, in total, directly or indirectly holds voting securities carrying 10 per cent or more of the votes carried by all outstanding voting securities. “Approved person” means, in respect of a member of the IDA (Member), an individual who is a partner, director, officer, employee or agent of a Member who is approved by the IDA or another Canadian self-regulatory organization to perform any function required under any IDA By-law, Regulation, or Policy. 1. Securities regulatory authorities a) Are you now, or have you ever been, registered or licensed with any securities regulator in any province, territory, state or country to trade in or advise on securities or derivatives? Yes No Check here if the information has been recorded on NRD under the NRD number you are using to make this submission. Otherwise, complete Schedule J, section 1(a) b) Have you ever been refused registration or a license to trade in or advise on securities or derivatives in any province, territory state or country? Yes No If “Yes”, complete Schedule J, section 1(b) c) Have you ever been denied the benefit of any exemption from registration provided by any securities regulator in any province, territory, state or country, other than what was disclosed in Item 8(3) of this form? Yes No If “Yes”, complete Schedule J, section 1(c)
8 d) 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 in any province, territory, state or country? Yes No If “Yes”, complete Schedule J, section 1(d) 2. Self-regulatory organizations a) Are you now, or have you ever been, an approved person of a self-regulatory organization or similar organization in any province, territory, state or country? Yes No Check here if the information has been recorded on NRD under the NRD number you are using to make this submission. Otherwise, complete Schedule J, section 2(a). b) Have you ever been refused becoming an approved person of a self-regulatory organization or similar organization in any province, territory, state or country? Yes No If “Yes”, complete Schedule J, section 2(b). c) Are you now, or have you ever been subject to any disciplinary proceedings conducted by any self-regulatory organization or similar organization in any province, territory, state or country? Yes No If “Yes”, complete Schedule J, section 2(c). 3. Non-securities regulation 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 in any province, territory, state or country (e.g. insurance, accountant, lawyer, teacher)? Yes No If “Yes”, complete Schedule J, section 3(a)
9 b) Have you ever been refused registration or a license under any legislation relating to your professional qualifications unrelated to securities in any province, territory, state or country? Yes No If “Yes”, complete Schedule J, section 3(b) c) Are you now, or have you ever been a subject of any disciplinary actions conducted under any legislation relating to your professional qualifications unrelated to securities in any province, territory, state or country? Yes No If “Yes”, complete Schedule J, section 3(c) Item 14 – Criminal disclosure Offences under federal statutes such as the Income Tax Act (Canada) and the Immigration Act (Canada) constitute criminal offences and must be disclosed when answering this question. It should be noted that pleas or findings of guilt for impaired driving are Criminal Code (Canada) matters and must be disclosed. Where you have pleaded guilty or been found guilty of an offence, such offence must be reported even though an absolute or conditional discharge has been granted. You are not required to disclose speeding, parking violations or any offence for which a pardon has been granted under the Criminal Records Act (Canada) and such pardon has not been revoked. Under such circumstances, the appropriate response would be “No”. If you do not tell us about an offence under any statute other than the Young Offenders Act (Canada),we may treat it as a non-disclosure of material information. a) Are there any outstanding or stayed charges against you alleging an offence that was committed in any province, territory, state or country? Yes No If “Yes”, complete Schedule K, section (a). b) Have you ever been convicted of, or pleaded guilty or no contest to, or were granted an absolute or conditional discharge from, any offence that was committed in any province, territory, state or country? Yes No
10 If “Yes”, complete Schedule K, section (b). c) Are there any outstanding charges against any firm of which you were, at the time the offence was alleged to have taken place in any province, territory, state or country, a partner, director, officer or major shareholder? Yes No If “Yes”, complete Schedule K, section (c). Check here if the firm is your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(a) and/or recorded on NRD. Otherwise, complete Schedule K, section (c). d) Has any firm, when you were a partner, officer, director or major shareholder, ever been convicted of or pleaded guilty or no contest to, or was granted an absolute or conditional discharge from, an offence that was committed in any province, territory, state or country? Yes No If “Yes”, complete Schedule K, section (d). Check here if the firm is your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(a) and/or recorded on NRD. Otherwise, complete Schedule K, section (d). Item 15 – Civil disclosure a) Are there currently any outstanding civil actions alleging fraud, theft, deceit, misrepresentation, or similar conduct against you in any province, territory, state or country? Yes No If “Yes”, complete Schedule L, section (a). b) Have you ever been a defendant or respondent in any civil proceeding in which fraud, theft, deceit, misrepresentation, or similar conduct is, or was, successfully established in a judgement in any province, territory, state or country? Yes No If “Yes”, complete Schedule L, section (b).
11 Item 16 – Financial disclosure 1. Bankruptcy Under the laws of any applicable jurisdictions, have you, or has any firm when you were a partner, director, officer or major shareholder of that firm: a) Had a petition in bankruptcy issued against you or the firm or made a voluntary assignment in bankruptcy? Yes No If “Yes”, complete Schedule M, section 1(a) b) Made a proposal under any legislation relating to bankruptcy or insolvency? Yes No If “Yes”, complete Schedule M, section 1(b) c) Been subject to proceedings under any legislation relating to the winding up, the dissolution, or the companies’ creditors arrangement? Yes No If “Yes”, complete Schedule M, section 1(c) d) Been subject to or initiated any proceedings, arrangement or compromise with creditors. This includes having a receiver, receiver-manager, administrator or trustee appointed by or at the request of creditors, privately, through court process or by order of a regulator, to hold your assets? Yes No If “Yes”, complete Schedule M, section 1(d) 2. Debt Obligations Have you ever failed to meet a financial obligation of $5,000 or more as it came due, or has any firm, while you were a partner, director, officer or major shareholder of, failed to meet a financial obligation as it came due? Yes No If “Yes”, complete Schedule M, section 2.
12 3. Surety bond or fidelity bond Have you ever been refused for a surety or fidelity bond? Yes No If “Yes”, complete Schedule M, section 3. 4. Garnishments, unsatisfied judgements or directions to pay Has any federal, provincial, territorial or state authority ever issued any of the following against you: Yes No Garnishment Unsatisfied judgement Direction to pay If “Yes”, complete Schedule M, section 4. Item 17 – Ownership of securities 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? Yes No If “Yes”, complete Schedule N Check here if the information has been recorded on NRD under the NRD number you are using to make this submission. Otherwise, complete Schedule N. Agent for service By submitting this form, you certify that in each Canadian jurisdiction where you have appointed an agent for service, you have completed the appointment of agent for service required in that jurisdiction.
13 Submission to jurisdiction By submitting this form, you: • are subject to the securities and/or derivatives legislation of each Canadian jurisdiction and you agree that you are subject to the by-laws, regulations, rules, rulings and policies (hereunder collectively referred to as “rules”) of the self regulatory organizations (SROs) to which you have submitted this form, including 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 and/or derivatives legislation or as an Approved Person under those SRO rules. Collection and use of personal information Securities regulators require personal information about you as part of the review of your application for registration or approval, and if you are approved, to assess whether you continue to meet the registration requirements. This information is collected under the requirements set out in securities and/or derivatives legislation and SRO rules and will only be used to administer and enforce provisions of this legislation or SRO rules. In addition to personal information collected on this form, securities regulators may also need to collect personal information from other government organizations, law enforcement bodies, self regulatory bodies, and private sector organizations. This information may include police records, regulatory records, credit records and other employment records. By submitting this form, you consent to the collection and disclosure of your personal information by securities regulators for registration and other related regulatory purposes. If you have any questions about the collection and use of your personal information, contact the securities regulator in the relevant jurisdiction. Please see Schedule O for details. In Québec, you can also contact the Commission d’accès à l’information at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca. Self-Regulatory Organizations The principal purpose for the collection of personal information is to assess your suitability for registration or approval and to assess your continued fitness for registration or approval in accordance with the applicable securities legislation and the rules of the self-regulatory organizations. By submitting this application, you authorize the self-regulatory organizations to which this application is submitted to collect any information from any source whatsoever, including, but not limited to, personal confidential information about you that is otherwise protected by law such as, police, credit, employment, education and proficiency course completion records, and records from other government or non-governmental regulatory authorities, securities
14 commissions, stock exchanges, or other self-regulatory organizations, private bodies, agencies, individuals or corporations, as may be necessary for the self-regulatory organizations to complete their review of your application or continued fitness for registration or approval in accordance with their rules for the duration of the period you remain so registered or approved. You further consent to and authorize the transfer of confidential information between self-regulatory organizations, securities commissions or stock exchanges to which you now, or may in the future, apply for registration or approval, or with which you are currently registered or approved for the purpose of determining fitness or continued fitness for registration or approval or in connection with the performance of an investigation or other exercise of regulatory authority, whether or not you are registered with or approved by them. By submitting this application, you certify that you are conversant with the rules of the applicable self-regulatory organizations of which you are seeking registration or approval or of which your sponsoring firm is a member or participating organization. You also undertake to become conversant with the rules of any self-regulatory organizations of which you or your sponsoring firm becomes a member or participating organization. You agree to be bound by, observe and comply with these rules as they are from time to time amended or supplemented, and you agree to keep yourself fully informed about them as they are amended and supplemented. You submit to the jurisdiction of the self-regulatory organizations to which you are applying for registration or approval, or of which your sponsoring firm is now or in the future becomes a member or participating organization and, wherever applicable, their Governors, Directors and Committees. You agree that any registration or approval granted pursuant to this application may be revoked, terminated or suspended at any time in accordance with the then applicable rules of the respective self-regulatory organizations. In the event of any such revocation or termination, you must terminate all activities which require registration or approval and, thereafter, not perform services that require registration or approval for any member of the self-regulatory organizations or any approved affiliated company or other affiliate of such member without obtaining the approval of or registration with the self-regulatory organizations, in accordance with their rules. By submitting this application, you undertake to notify the self-regulatory organizations to which you are applying for registration or approval or with which you are currently or may in the future be registered or approved of any material change to the information herein provided in accordance with their respective rules. You agree to the transfer of this application form, without amendment, to other self-regulatory organizations in the event that at some time in the future you apply to such other self-regulatory organizations for registration or approval. You certify that you have discussed the questions in this application, together with this Agreement, with an Officer or Branch Manager of your sponsoring member firm and, to your knowledge and belief, the authorized Officer or Branch Manager was satisfied that you fully understood the questions and the terms of this Agreement. You further certify that your business activities will be limited strictly to those permitted by the category of your registration or approval. It is an offence under securities and/or derivatives legislation to provide false or misleading information on this form.
15 [Online version] Certification I am making this submission as agent for the applicant. By checking this box, I certify that the applicant provided me with all of the information on this form. [Paper version] Signatures Applicant By signing below, you confirm that: • you have read and understand the questions in this form • you understand that it is an offence under [the securities and/or derivatives legislation] to provide false or misleading information on this form • all of the information provided on this form is true. Signature of applicant Date Authorized partner or officer By signing below, you confirm that: • the applicant will be engaged by the sponsoring firm as a registered individual or a permitted individual • you have discussed the questions set out in this form with the applicant and are satisfied that he or she fully understands the questions. Name of firm Name of authorized signing officer Title of authorized signing officer Signature Date signed (YYYY/MM/DD)
16 SCHEDULE A Name Item 1 Other personal names Last name First name Second name Third name (if applicable) (if applicable) Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name, nickname, style names or trade names). When did you use this name? From: To: (YYYY/MM) (YYYY/MM) Last name First name Second name Third name (if applicable)) (if applicable) Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name, nickname, style names or trade names). When did you use this name? From: To: (YYYY/MM) (YYYY/MM) Last name First name Second name Third name (if applicable) (if applicable) Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name, nickname, style names or trade names). When did you use this name? From: To: (YYYY/MM) (YYYY/MM) Business names Name: Provide the reason(s) for the use of this name: When did you use this name? From: To: (YYYY/MM) (YYYY/MM) If the name is/was used in connection with your sponsoring firm, did the sponsoring firm approve the use of the name? Name: Provide the reason/s for the use of this name: When did you use this name? From: To: (YYYY/MM) (YYYY/MM)
17 SCHEDULE B Residential address Item 2 Previous addresses A postal code (or ZIP code) and a telephone number are not required for any previous address. Residential address: (number, street, city, province, territory or state, country) When did you live at this address? From: To: (YYYY/MM) (YYYY/MM) Residential address: (number, street, city, province, territory or state, country) When did you live at this address? From: To: (YYYY/MM) (YYYY/MM) Residential address: (number, street, city, province, territory or state, country) When did you live at this address? From: To: (YYYY/MM) (YYYY/MM) Residential address: (number, street, city, province, territory or state, country) When did you live at this address? From: To: (YYYY/MM) (YYYY/MM) Residential address: (number, street, city, province, territory or state, country) When did you live at this address? From: To: (YYYY/MM) (YYYY/MM)
18 SCHEDULE C INDIVIDUAL CATEGORIES Item 6 Categories Indicate, by checking the appropriate box, each category for which you are applying. Individual Category Information Relationship with Sponsoring Firm □ Officer □ Partner □ Director □ Sole Proprietor □ Investor □ Representative – Employee □ Representative – Non-Employee Supervisory Roles □ Compliance Officer □ Branch Manager □ Co-Branch Manager □ Assistant Branch Manager □ Chief Compliance Officer □ Ultimate Designated Person □ Alternate Designated Person □ Designated Options Principal □ Alternate Options Principal □ Designated Futures Options Principal □ Alternate Futures Options Principal □ Futures Contract Options Supervisor Products □ Securities □ Mutual Funds □ Scholarship Plans Traders □ Floor Trader □ Floor Broker □ Local □ Trader – CATS □ Trader – TradeCDNX □ Trader – Commodity Floor Trader Registration by Jurisdiction Trading Advising Associate Alberta□□□ British Columbia□□□ Manitoba□□□ New Brunswick□□□ Newfoundland and Labrador□□□ Northwest Territories□□□
19 Nova Scotia□□□ Nunavut□□□ Ontario□□□ Prince Edward Island□□□ Québec□□□ Saskatchewan□□□ Yukon□□□ Investment Dealers Association of Canada – Additional Information Partner, Director, Investor (check one) □ Industry □ Non-Industry Representative (check one) □ Registered Representative □ Investment Representative SCHEDULE D Address and agent for service 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 applying 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: ( ) E-mail address: 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
20 SCHEDULE E Proficiency Item 8 COURSE OR EXAMINATION DATE COMPLETED DATE EXEMPTED AND BY WHICH JURISDICTION OR REGULATOR (YYYY/MM/DD) OTHER
21 SCHEDULE F Proficiency Item 8 Exemption refusal Complete the following for each exemption that was refused. Which securities regulatory authority or self-regulatory organization refused to grant the exemption? State the name of the course, examination or experience requirement: State the reason given for not being granted the exemption: Date exemption refused: (YYYY/MM/DD) Which securities regulatory authority or self-regulatory organization refused to grant the exemption? State the name of the course, examination or experience requirement: State the reason given for not being granted the exemption: Date exemption refused: (YYYY/MM/DD)
22 SCHEDULE G Current employment and other business activities Item 10 Full-time student Employed or self-employed From: (YYYY/MM/DD) You are only required to fill in the following if you have indicated above that you are employed or self-employed. Current Employment information Check here if your employment is with your sponsoring firm. If not, provide the following information: 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: For your sponsoring firm, include the duties you currently perform and intend to perform. Describe all other employment or business activities, whether or not the activities are related to investments. Include the nature of the business, your duties, start date, title or relationship with the business (including director or officer positions). Indicate the number of hours per week you will be devoting to this business or employment. Check here if you are working more than 30 hours per week for the sponsoring firm. Otherwise, explain why you are working less than 30 hours per week for the sponsoring firm. Disclose any potential for confusion by clients and any potential for conflicts of interest arising from your proposed activities as a registrant with affiliated or unaffiliated sponsoring firm(s) and with the other business described above (include whether the other business is listed on an exchange). Confirm whether the firm has procedures for minimizing potential conflicts of interest and confirm that you are aware of these procedures.
23 SCHEDULE H Previous employment Item 11 Previous employment information Provide the information requested for your previous business and employment activities for the 10-year period before the date of this application. Account for all time including full and part-time employments, self-employment, military service and homemaking. Include statuses such as unemployed, full-time education, extended travel, or other similar statuses. (Please do not include short-term employment (four months or less) while a student unless it was in the securities industry.) In addition, provide the information requested for all of your securities or derivatives (including exchange contracts and options) business and employment activities during and prior to the ten-year period. Unemployed Full-time student Employed or self-employed From: (YYYY/MM) To: (YYYY/MM) You are only required to fill in the following if you have indicated above that you are, or were, employed or self-employed. Start date: (YYYY/MM) End date: (YYYY/MM) 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. If you are applying for a type of registration that requires specific experience, include details of that experience (for example, level of responsibility, value of accounts under direct supervision, number of year of that experience and research experience, as well as percentage of time spent on each activity): Reason why you left the firm
24 Start date: (YYYY/MM) End date: (YYYY/MM) 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 and your duties. If you applying for a type of registration that requires specific experience, include details of that experience (for example, level of responsibility, value of accounts under direct supervision, number of year of that experience and research experience, as well as percentage of time spent on each activity): Reason why you left the firm
25 SCHEDULE I Resignations and terminations Item 12 For each resignation, termination or employment that was discharged for cause, indicate below, (1) the name of the firm from which you resigned, were terminated or discharged for cause, (2) whether you resigned, were terminated or discharged for cause, (3) the date you resigned, were terminated or discharged for cause, and (4) the circumstances relating to your resignation, termination or discharge for cause.
26 SCHEDULE J Regulatory disclosure Item 13 1. Securities regulatory authorities a) For each registration or license, indicate below (1) the name of the firm, (2) the securities regulatory authority with which you are, or were, registered or licensed, (3) the type or category of registration or license, and (4) the dates between which you held the registration or license. ……………………. b) For each registration or license refused, indicate below (1) the name of the firm, (2) the securities regulatory authority that refused the registration or license, (3) the type or category of registration or license refused, (4) the date of the refusal, and (5) the reasons for the refusal. …………………….. c) For each exemption from registration denied or license refused , other than what was disclosed in Item 8(3) of this form, indicate below (1) the party that was refused the registration or license, (2) the securities regulatory authority that refused the registration or license, (3) the type or category or registration or license refused, (4) the date of the refusal, and (5) the reasons for the refusal. …………………….. d) For each order or disciplinary proceeding, indicate below (1) the name of the firm, (2) the securities regulatory authority 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. ……………………… 2. Self-regulatory organizations a) For each approval, indicate below (1) The name of the firm, (2) the self-regulatory organization which you are or were an approved person, (3) the categories of approval, and (4) the dates you held the approval. ……………………. b) For each approval refused, indicate below (1) the name of the firm, (2) the self-regulatory organization that refused the approval, (3) the category of approval refused, (4) the date of the refusal, and (5) the reasons for the refusal. …………………….. c) For each order or disciplinary proceeding, indicate below (1) the name of the firm, (2) the self-regulatory organization 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
27 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 information that you think is relevant or that is requested by the regulator. ……………………... 3. Non-securities regulation a) For each registration or license, indicate below (1) who the party is, or was, registered or licensed, (2) with which regulatory authority, or under what legislation, the party is, or was, registered or licensed, (3) the type or category of registration or license, and (4) the dates between which the party held the registration or license. ……………………… b) For each registration or license refused, indicate below (1) the party that was refused registration or licensing, (2) with which regulatory authority, or under what legislation, the registration or license was refused, (3) the type or category of registration or license refused, (4) the date of the refusal, and (5) the reasons for the refusal. ……………………… c) 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 firm and named individually in the order or disciplinary proceeding and (7) any other information that you think is relevant or that is requested by the regulator.
28 SCHEDULE K Criminal disclosure Item 14 Criminal offences a) For each charge, indicate below (1) the type of charge, (2) the date of the charge, (3) any trial or appeal dates, and (4) the court location. b) For each conviction, indicate below (1) the offence, (2) the date of the conviction, and (3) the disposition (state any penalty or fine and the date any fine was paid). c) For each charge, indicate below (1) the name of the firm, (2) the type of charge, (3) the date of the charge, (4) any trial or appeal dates, and (5) the court location. d) For each conviction, indicate below (1) the name of the firm, (2) the offence, (3) the date of the conviction, and (4) the disposition (state any penalty or fine and the date any fine was paid).
29 SCHEDULE L Civil disclosure Item 15 a) For each current and outstanding civil proceeding, state below (1) the dates the statement of claim and statement of defence were issued, (2) each plaintiff in the proceeding, (3) whether the proceeding is pending or on appeal, (4) whether the civil proceeding was about a firm 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. b) For each civil proceeding, state below (1) the dates the statement of claim and statement of defence were issued, (2) each plaintiff in the proceeding, (3) the jurisdiction where the action was pursued, (4) whether the civil proceeding was about a firm 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. (Disclosure must include those actions settled without admission of liability.)
30 SCHEDULE M Financial Disclosure Item 16 1. Bankruptcy a) For each event, indicate below (1) the date of the petition or voluntary assignment, (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, (7) date of discharge or release, if applicable, and (8) any other information that you think is relevant or that is requested by the regulator. b) For each event, indicate 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 other information that you think is relevant or that is requested by the regulator. c) For each event, indicate below (1) the date of the proceeding, (2) the person or firm about whom this disclosure is being made, (3) the status of the matter, (4) a summary of any disposition or settlement, and (5) any other information that you think is relevant or that is requested by the regulator. d) For each proceeding, arrangement or compromise with creditors, indicate below (1) the date of the proceeding, (2) the person or firm about whom this disclosure is being made, (3) the status of the matter, (4) a summary of any disposition or settlement, and (5) any other information that you think is relevant or that is requested by the regulator. 2. Debt Obligation For each event, indicate below (1) the person or firm that failed to meet its financial obligation, (2) the amount that was owing at the time the person or firm failed to meet its financial obligation, (3) the person or firm 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 other information that you think is relevant or that is requested by the regulator. 3. Surety Bond or Fidelity Bond For each bond refused, indicate 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. 4. Garnishments, Unsatisfied Judgements or Directions to Pay For each garnishment, unsatisfied judgement or direction to pay, indicate below (1) the amount that was owing at the time the garnishment, judgement or direction to pay was rendered, (2) the person or firm 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) the percentage of earnings to be
31 garnished, (5) any amounts currently owing, and (6) any other information that you think is relevant or that is requested by the regulator.
32 SCHEDULE N Ownership of securities firms Item 17 Indicate below (a) the name of the firm and (b) your relationship to the firm. a) Firm name: b) Relationship to the firm and period of relationship: Partner From: / To: / (if applicable) (YYYY/MM) (YYYY/MM) Major shareholder (as defined in Item 13 of this form) From: / To: / (if applicable) (YYYY/MM) (YYYY/MM) If you are a partner or major shareholder of the firm, 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 upon approval. If acquiring shares upon approval, state source (for example, treasury shares, or if upon transfer, state name of transferor). b) State the value (approximate, if necessary) of 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 applicable): c) If another person or firm has provided you with funds to invest in the firm, identify the person or firm and state the relationship between you and that person or firm: d) Are the funds to be invested (or proposed to be invested) guaranteed directly or indirectly by any person or firm? Yes No If “Yes”, identify the person or firm and state the relationship between you and that person or firm: e) Have you either directly or indirectly given up any rights with respect to such securities or partnership interest, or do you, on approval of this application, intend to give up any such rights (including by hypothecation, pledging or depositing as collateral the securities or partnership interest with any institution or person? Yes No If “Yes”, identify the person or firm, state the relationship between you and that person or firm and describe the rights that have been or will be given up:
33 f) Is a person other than you the beneficial owner of the shares, bonds, debentures, partnership units or other notes held by you? Yes No If “Yes”, complete (g), (h) and (i). g) Name of beneficial owner: Last name First name Second name Third name (if applicable) (if applicable) h) Residential address: (number, street, city, province, territory or state, country, postal code) i) Occupation:
34 SCHEDULE O Who to contact if you have questions about the collection and use of your personal information. Contact Information Alberta Alberta Securities Commission, 4th Floor, 300 B 5th Avenue S.W. Calgary, AB T2P 3C4 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: Freedom of Information Officer Telephone: (604) 899-6500 or (800) 373-6393 (in BC) Manitoba The Manitoba Securities Commission 500 – 400 St. Mary Avenue Winnipeg, MB R3C 4K5 Attention: Director – Legal Telephone: (204) 945-0605 New Brunswick New Brunswick Securities Commission Suite 300, 85 Charlotte Street Saint John, NB E2L 2J2 Attention: Director, Market Regulation Telephone: (506) 658-3021 Newfoundland and Labrador Securities Commission of Newfoundland and Labrador P.O. Box 8700, 2nd Floor, West Block Confederation Building St. John's, NF A1B 4J6 Attention: Director of Securities Tel: (709) 729-4189
35 Nova Scotia Nova Scotia Securities Commission 2nd Floor, Joseph Howe Building 1690 Hollis Street P.O. Box 458 Halifax, NS B3J 3J9 Attention: FOI Officer Telephone: (902) 424-7768 Northwest Territories Government of the Northwest Territories P.O. Box 1320 Yellowknife, NWT X1A 2L9 Attention: Deputy Registrar of Securities Telephone: (867) 920-8984 Nunavut Legal Registries Division Department of Justice Government of Nunavut P.O. Box 1000 Station 570 Iqaluit, NU X0A 0H0 Attention: Deputy Registrar of Securities Telephone: (867) 975-6190 Ontario Ontario Securities Commission Suite 1903, Box 55 20 Queen Street West Toronto, ON M5H 3S8 Attention: FOI Coordinator Telephone: (416) 593-8314 Prince Edward Island Securities Registry Office of the Attorney General B Consumer, Corporate and Insurance Services Division P.O. Box 2000 Charlottetown, PE C1A 7N8 Attention: Deputy Registrar of Securities Telephone: (902) 368-4569
36 Québec Autorité des marchés financiers Stock Exchange Tower P.O. Box 246, 22nd Floor 800 Victoria Square Montréal, PQ H4Z 1G3 Attention: Responsable de l’accès à l’information Telephone: (514) 395-0337 or (877) 525-0337 (in Québec) Saskatchewan Saskatchewan Financial Services Commission 800 B1920 Broad Street Regina, SK S4P 3V7 Attention: Director Telephone: (306) 787-5842 Yukon Department of Community Services Yukon P.O. Box 2703 Whitehorse, YU Y1A 2C6 Attention: Registrar of Securities Telephone: (867) 667-5225
You are being directed to the most recent version of the statute which may not be the version considered at the time of the judgment.