FORM 33-109F2 CHANGE OR SURRENDER OF INDIVIDUAL CATEGORIES (section 2.2(2), 2.4, 2.6(2) or 4.1(4)) GENERAL INSTRUCTIONS Complete and submit this f orm to no tify the relevant regulator(s) or, in Qu ébec, the securities regulatory authority, or self-regulatory organization (S RO) that a registered individual or perm itted individual seeks to add and/or re move individual registration categories or permitted activities. Terms In this form, “you”, “your” and “individual” mean the registered individual or permitted individual who is seeking to add and/or remove registration categories or permitted activities. How to submit this form Submit this form at the National Registration Database (NRD) website in NRD format at www.nrd.ca. If you are rel ying on the temporary hardship exemption in se ction 5.1 of N ational Instrument 31-102, you may submit this form in a format other than NRD format. Item 1 Individual Name of individual ______________________________________ NRD number of individual ________________________________ Item 2 Registration jurisdictions 1. Are you filing this form under the passport system / interface for registration? Choose “no” if you are registered in: (a) only one jurisdiction in Canada (b) more than one jurisdiction in Canada and you are requ esting a su rrender in a non-principal jurisdiction or jurisdictions, but not in your principal jurisdiction (c) more than one jurisdiction in Canada and you are requesting a change only in your principal jurisdiction Yes No 2. Check each jurisdiction where you are seeking the change or surrender of individual categories of registration. Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon Item 3 Removing categories What categories are you seeking to remove?
Item 4 Adding categories 1. Categories What categories are you seeking to add? 2. Professional liability insurance (Québec mutual fund dealers and Québec scholarship plan dealers) If you are seeking registration as a representative of a mutual fund dealer or of a s cholarship plan dealer in Québec, are you covered by your sponsoring firm’s professional liability insurance? Yes No If “No”, state: The name of your insurer Your policy number 3. Relevant securities industry experience If you have not been registered in the last 36 months and you passed the required examination more than 36 months ago, do you consider that you have gained 12 months of relevant securities industry experience during the 36 month period? Yes No N/A If you are an individual applying for IIROC approval, select “Not Applicable” above. If “yes”, complete Schedule A. Item 5 Reason for surrender If you are seeking to remove a category or permitted activity, state the reason for the surrender in the local jurisdiction. _________________________________________________________________________________________________ Item 6 Notice of collection and use of personal information The personal information r equired u nder th is form is col lected o n behalf of, a nd us ed by , the sec urities r egulatory authorities in the juris dictions set out in Sched ule A to administer and enforce c ertain pro visions of t heir securi ties legislation or derivatives legislation or both. The personal information required under this form is also col lected by and used by the SROs set out in Sch edule A to administer and enforce their respective by-laws, regulations, rules, rulings and policies. By submitting this form , the in dividual consents to the col lection by the se curities regulatory authorities or a pplicable SRO of this person al i nformation, and any po lice records, rec ords fro m other go vernment or n on-governmental regulators or SROs, credit records and employment records about the individual that the securities regulatory authorities or ap plicable SRO may need to c omplete t heir revi ew of the in formation su bmitted i n t his form relatin g to the individual’s continued fit ness for registra tion or approval, if a pplicable, i n ac cordance wit h t he leg al authority of the securities regulatory authorities while the individual is registered with or approved by it. Securities regulatory authorities or SROs may contact government and private bodies or agencies, individuals, corporations and other organizations for information about the individual.
If you have any questions about the collection and use of this information, contact the securities regulatory authorities or applicable SRO in any jurisdiction in which the required information is submitted. See Schedule A for details. In Québec, you ca n als o conta ct t he Com mission d’ac cès à l’inform ation at 1-888-528-7741 or visit its w ebsite at www.cai.gouv.qc.ca. Item 7 Warning It is an offence under securities legislation and/or derivatives legislation, including commodity futures legislation to give false or misleading information on this form. Item 8 Certification Certification-NRD format: I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm. To the best of my knowledge and belief, the officer, branch manager or supervisor was satisfied that I fully understood the questions. I will limit my activities to those permitted by my category of registration. I am making this submission as agent for the individual identified in this form. By che cking this box, I certify that the individual provided me with all of the information on this form. Certification-Format other than NRD format: By signing below: 1. I certify to the regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form, either directly or through the principal regulator, that: I have read this form and understand the questions, and all of the information provided on this form is true, and complete. 2. I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm. To the best of my knowledge and belief, the officer, branch manager or supervisor was satisfied that I fully understood the questions. I will limit my activities to those permitted by my category of registration. Signature of individual__________________________ Date signed (YYY Y/MM/DD)
By signing below, I certify to the regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form for the individual, either directly or through the principal regulator, that: 1. the individual identified in this form will be engaged by the firm as a registered individual, or a non registered individual, and 2. I have, or a branch manager or supervisor or another officer or partner has, discussed the questions set out in this form with the individual. To the best of my knowledge and belief, the individual fully understands the questions. Name of firm _______________________________________________________________ Name of authorized signing officer or partner ______________________________________ Title of authorized signing officer or partner _______________________________________ Signature of authorized signing officer or partner Date signed ________________________ (YYY Y/MM/DD)
SCHEDULE A Relevant securities industry experience (Item 4) Describe your responsibilities in areas relating to the category you are applying for, including the title(s) you have held, as well as start and end dates: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ What is the percentage of your time devoted to these activities? _____ % Indicate th e continuing education act ivities wh ich you h ave participated in during th e last 36 months an d which are relevant to the category of registration you are applying for: _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________
Schedule B Contact information for Notice of 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) 355-4151 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 of Registrations Telephone (204) 945-2548 Fax (204) 945-0330 New Brunswick New Brunswick Securities Commission Suite 300, 85 Charlotte Street Saint John, NB E2L 2J2 Attention: Director, Regulatory Affairs Telephone: (506) 658-3060 Newfoundland and Labrador Securities NL Financial Services Regulation Division Department of Government Services P.O. Box 8700, 2nd Floor, West Block Confederation Building St. John's, NL A1B 4J6 Attention: Manager of Registrations Tel: (709) 729-5661 Nova Scotia Nova Scotia Securities Commission Suite 400, 5251 Duke Street Halifax, NS B3J 1P3 Attention: Deputy Director, Capital Markets Telephone: (902) 424-7768 Northwest Territories Government of the Northwest Territories P.O. Box 1320 Yellowknife, NWT X1A 2L9 Attention: Deputy Superintendent 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) 975-6590 Ontario Ontario Securities Commission Suite 1903, Box 55 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 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) 368-6288 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 (in Québec) Saskatchewan Saskatchewan Financial Services Commission Suite 601, 1919 Saskatchewan Drive Regina, SK S4P 4H2 Attention: Director Telephone: (306) 787-5842 Yukon Yukon Securities Office Department of Community Services P.O. Box 2703 C-6 Whitehorse, YT Y1A 2C6 Attention: Superintendent of Securities Telephone: (867) 667-5225 Self-regulatory organization Investment Industry Regulatory Organization of Canada 121 King Street West, Suite 1600 Toronto, Ontario M5H 3T9 Attention: Privacy Officer Telephone: (416) 364-6133 E-mail: PrivacyOfficer@iiroc.ca
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.