APPENDIX “A” SUBMISSION TO JURISDICTION AND APPOINTMENT OF AGENT FOR SERVICE INTERNATIONAL ADVISER EXEMPTED FROM REGISTRATION UNDER THE COMMODITY FUTURES ACT (MANITOBA)
1. 2.
3. 4. 5.
Name of person or company (“International Firm”): If the International Firm was previously assigned an NRD number as a registered firm or an unregistered exempt international firm, provide the NRD number of the firm.
Jurisdiction of incorporation of the International Firm: Head office address of the International Firm: The name, e-mail address, phone number and fax number of the International Firm’s individual(s) responsible for the supervisory procedure of the International Firm, its chief compliance officer, or equivalent.
Name: E-mail address: Phone: Fax:
6.
The International Firm is relying on an exemption order under section 66 of the Commodity Futures Act (Manitoba) that is similar to the following exemption in National Instrument 31-103, Registration Requirements, Exemptions and Ongoing Registrant Obligations (the “Relief Order”):
Section 8.18 [international dealer] Section 8.26 [international adviser] Other [specify]
7. 8. 9.
10.
11.
Name of agent for service of process (the "Agent for Service"): Address for service of process on the Agent for Service: The International Firm designates and appoints the Agent for Service at the address stated above as its agent upon whom may be served a notice, pleading, subpoena, summons or other process in any action, investigation or administrative, criminal, quasi-criminal or other proceeding (a “Proceeding”) arising out of or relating to or concerning the International Firm’s activities in the local jurisdiction and irrevocably waives any right to raise as a defence in any such proceeding any alleged lack of jurisdiction to bring such Proceeding.
The International Firm irrevocably and unconditionally submits to the non-exclusive jurisdiction of the judicial, quasi-judicial and administrative tribunals of the local jurisdiction in any Proceeding arising out of or related to or concerning the International Firm’s activities in the local jurisdiction.
Until 6 years after the International Firm ceases to rely on the Relief Order, the International Firm must submit to the regulator
a.
b.
a new Submission to Jurisdiction and Appointment of Agent for Service in this form no later than the 30th day before the date this Submission to Jurisdiction and Appointment of Agent for Service is terminated;
an amended Submission to Jurisdiction and Appointment of Agent for Service no later than the 30th day before any change in the name or above address of the Agent for Service; and
12.
c.
a notice detailing a change to any information submitted in this form, other than the name or above address of the Agent for Service, no later than the 30th day after the change.
This Submission to Jurisdiction and Appointment of Agent for Service is governed by and construed in accordance with the laws of the local jurisdiction.
Dated:
(Signature of the International Firm or authorized signatory)
(Name and Title of authorized signatory)
Acceptance The undersigned accepts the appointment as Agent for Service of under the terms and conditions of the foregoing Submission to Jurisdiction and Appointment of Agent for Service.
Dated:
(Signature of the Agent of Service or authorized signatory)
(Name and Title of authorized signatory)
APPENDIX “B” Notice of Regulatory Action
1. Has the firm, or any predecessors or specified affiliates 1 of the firm entered into a settlement agreement with any financial services regulator, securities or derivatives exchange, SRO or similar organization or similar agreement with any financial services regulator, securities or derivatives exchange, SRO or similar organization?
Yes No If yes, provide the following information for each settlement agreement:
Name of entity Regulator/organization Date of settlement (yyyy/mm/dd) Details of settlement Jurisdiction
2.
Has any financial services regulator, securities or derivatives exchange, SRO or similar organization:
(a) Determined that the firm, or any predecessors or specified affiliates of the firm violated any securities regulations or any rules of a securities or derivatives exchange, SRO or similar organization?
Yes
No
(b) Determined that the firm, or any predecessors or specified affiliates of the firm made a false statement or omission?
(c) Issued a warning or requested an undertaking by the firm, or any predecessors or specified affiliates of the firm?
(d) Suspended or terminated any registration, licensing or membership of the firm, or any predecessors or specified affiliates of the firm?
(e) Imposed terms or conditions on any registration or membership of the firm, or predecessors or specified affiliates of the firm?
(f) Conducted a proceeding or investigation involving the firm, or any predecessors or specified affiliates of the firm?
(g) Issued an order (other than an exemption order) or a sanction to the firm, or any predecessors or specified affiliates of the firm for securities or derivatives-related activity (e.g. cease trade order)?
1 In Appendix, the term "specified affiliate" has the meaning ascribed to that term in Form 33-109F6 to National Instrument 33-109 Registration Information.
If yes, provide the following information for each action:
Name of entity Type of action Regulator/organization Date of action (yyyy/mm/dd) Jurisdiction
Reason for action
3. Is the firm aware of any ongoing investigation of which the firm or any of its specified affiliates is the subject? Yes No If yes, provide the following information for each action:
Name of entity Reason or purpose of investigation Regulator/organization Date investigation commenced (yyyy/mm.dd) Jurisdiction
Name of firm Name of firm’s authorized signing officer or partner Title of firm’s authorized signing officer or partner Signature: Date (yyyy/mm/dd)
Witness The witness must be a lawyer, notary public or commissioner of oaths.
Name of witness Title of witness Signature Date (yyyy/mm/dd)