FORM 33-109F4 REGISTRATION OF INDIVIDUALS AND REVIEW OF PERMITTED INDIVIDUALS (section 2.2)
GENERAL INSTRUCTIONS Complete a nd submit this f orm to th e rel evant re gulator(s) or in Qué bec, t he se curities reg ulatory auth ority, or self-regulatory organization (SRO) if an individual is seeking registration in individual categories or is seeking to be reviewed as a permitted individual. You only need to complete and submit one of this form regardless of the number of categories you are seeking to be registered in.
Terms In this form , “you”, “your” and “ individual” mean the individual who is seeking registra tion or the in dividual who is filing this form as a permitted individual under securities legislation or derivatives legislation or both.
“Sponsoring firm” means the registered firm where you will carry out your duties as a registered or permitted individual. “Derivatives” means fina ncial i nstruments, s uch as futures contracts (i ncluding ex change tra ded contra cts), futures options a nd s waps w hose market pri ce, va lue or p ayment o bligations are derived from , or based on, o ne or more underlying interests. Derivatives can be in the form of instruments, agreements or securities.
“Major shareholder” and “shareholder” mean a share holder who, in to tal, d irectly or ind irectly owns vo ting securities carrying 10 per cent or more of the votes carried by all outstanding voting securities.
“Approved person” means, in respec t of a member (Member) of the Inv estment Industry Regulatory Organization of Canada (IIROC), an individual who is a partner, director, officer, employee or agent of a Me mber who is appr oved by the IIROC or another Canadian SRO to perform any function required under any IIROC or another Canadian SRO By-law, Regulation, or Policy.
Several terms used in this form are defined in the securities legislation of your province or territory. Please refer to those definitions.
How to submit this form NRD format Submit th is fo rm at th e N ational Reg istration Datab ase (NRD) we bsite in NRD fo rmat at www.n rd.ca. Y ou are on ly required t o s ubmit one fo rm regardless of the number of registra tion categories y ou are see king. If y ou have any questions, c ontact th e co mpliance, reg istration or le gal d epartment of the sp onsoring firm or a lega l ad viser w ith securities regulation experience, or visit the NRD information website at www.nrd-info.ca.
Format, other than NRD format If y ou are re lying on t he tem porary hardshi p e xemption in sect ion 5.1 of N ational Ins trument 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 fo rm, and send it to the re levant regulator(s) o r, in Québec, the securities regulatory authority, SRO (s) or si milar authority. The number of origi nally signed copies of t he form you are requ ired 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 a nswer all of the ques tions that apply to you. If you have questions, contact th e c ompliance, re gistration or legal d epartment of the s ponsoring firm or a leg al a dviser with s ecurities regulation experience, or visit the National Registration Database information website at www.nrd-info.ca.
Item 1 Name 1. Legal name Last name First name Second name (N/A ) Third name (N/A ) NRD number (if applicable) 2. Other personal names Are you currently , or ha ve you ever be en, known by any names other tha n your full leg al name above, for example, nicknames or names due to marriage?
Yes No If “yes”, complete Schedule A. 3. Use of other names Are you currently, or have you ever used, operated under, or carried on business under any 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 Residential address Provide all of your residential addresses, including any foreign residential addresses, for the past 10 years. 1. Current and previous residential addresses (number, street, city, province, territory or state, country, postal code) Telephone number Lived at this address since (YYYY/MM) If you have lived at this address for less than 10 years, complete Schedule B. 2. Mailing address Check here if y our mailing address is t he same as y our current resi dential 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. Gender Female Male 4. Eye colour 5. Hair colour 6. Height in. or cm 7. Weight lbs. or kg Item 4 Citizenship 1. Citizenship information What is your country of citizenship? Canada Other, specify: 2. If you are a citizen of a country other than Canada, complete the following for that citizenship. Check here if you do not have a valid passport. Otherwise, provide: Passport number: ______________________________________________ Date of issue: _________________________________________________ (YYY Y/MM/DD) Place of issue: ________________________________________________ (city, province, territory or state, country)
Item 5 Registration jurisdictions 1. Are you filing this form under the passport system / interface for registration? Only choose “no” if: (a) you are seeking registration only in your principal jurisdiction, (b) you are seeking review as a permitted individual only in your principal jurisdiction
and you are not currently registered under securities legislation in any jurisdiction of Canada, Yes No
2. Check each jurisdiction where you are seeking registration or review as a permitted individual: All jurisdictions Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon
Item 6 Individual categories 1. On Sched ule C, che ck ea ch cate gory for w hich y ou are s eeking r egistration as an individual or review as a permitted individual. If you are see king review as a permitted individual, check each category that describes your position with your sponsoring firm. 2. If y ou are see king re gistration as a re presentative of a mutual fund dea ler or of a scholarship pl an 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 Item 7 Address and agent for service 1. Address for service You must have one address for servic e in each province or terri tory where y ou are submitting this form. A reside ntial address or a business addres s is acceptable. A pos t office box is not acceptable. Complete Schedule D for ea ch additional address for service you are providing.
Address for service: (number, street, city, province or territory, postal code) Telephone number Fax number, if applicable E-mail address, if available
2. Agent for service If you have appointed an agent for service, provide the following information for the a gent in each province or territory where you have an agent for service. The address of your agent for s ervice must be the sam e 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: _______________________________________________ L ast name, First name Item 8 Proficiency 1. Course, examination or designation information and other education Complete Schedule E to i ndicate each course, examination and designation that is requ ired for registra tion or a pproval and that you have successfully completed or have been exempted from.
Check here if you are not required under securities legislation or derivatives legislation or both, or the rules of an SRO to satisfy any course, examination or designation requirements.
2. Student numbers If y ou ha ve a stu dent number for a c ourse tha t y ou s uccessfully c ompleted w ith one of the fol lowing organizations, provide it below:
CSI Global Education (formerly Canadian Securities Institute): IFSE Institute (formerly IFIC): Institute of Canadian Bankers (ICB): CFA Institute (formerly AIMR): Advocis (formerly CAIFA): RESP Dealers Association of Canada: Other: 3. Exemption refusal Has any securities regulator, derivatives regulator or SRO refused to grant you an exemption from a course, examination, designation or experience requirement?
Yes No If “Yes”, complete Schedule F.
4. Relevant securities industry experience If you are an individual applying for IIROC approval, select “Not Applicable below”. 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 “yes”, complete Schedule F. Item 9 Location of employment 1. Provide the following information for y our new sp onsoring firm. 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: Unique Identification Number (optional) : _________________________________________ Business address: ____________________________________________________________ (number, street, city, province, territory or state, country, postal code)
Telephone number: ( ) Fax number: ( ) 2. If the firm has a foreign head office, and/or you are not a resident of Canada, provide the address for the location in which you will be conducting business. Business address: ____________________________________________________________ (number, street, city, province, territory or state, country, postal code)
Telephone number: ( ) Fax number: ( ) [The following under #3 “Type of location”, #4 and #5 is for a Format other than NRD format only] 3. Type of location - for Format other than NRD format only: Head office Branch or Business Location Sub-branch 4. Name of supervisor or branch manager: 5. Check here if the mailing address of the location is the same as the business address provided above. Otherwise, complete the following:
Mailing address: __________________________________________________________________________ (number, street, city, province, territory or state, country, postal code)
Item 10 Current employment, other business activities, officer positions held and directorships Complete a separate Schedule G for each of your current business and employment activities, including employment and business activities with your s ponsoring firm and any em ployment and business activities outside your sponsoring firm. Also in clude all business r elated officer or d irector p ositions an d any ot her equivalent positions held, w hether y ou receive compensation or not.
Item 11 Previous employment and other activities On Schedule H, complete your employment and other activities history for the past 10-years. Item 12 Resignations and terminations Have y ou e ver resigne d, been term inated or be en d ismissed for cause by an em ployer from a positio n follow ing allegations that you:
1. Violated any statutes, regulations, rules or standards of conduct? Yes No If “Yes”, complete Schedule I Item 12.1. 2. Failed to appropriately supervise compliance with any statutes, regulations, rules or standards of conduct? Yes No If “Yes”, complete Schedule I Item 12.2. 3. Committed fraud or the wrongful taking of property, including theft? Yes No If “Yes”, complete Schedule I Item 12.3. Item 13 Regulatory disclosure 1. Securities and derivatives regulation a) Other than a registration or permitted individual status that has been recorded under this NRD nu mber, are you now, or have you ever been, registered or licensed with any securities regulator or derivatives regulator or both in any province, territory, state or country to trade in or advise on securities or derivatives or both?
Yes No If “Yes”, complete Schedule J, Item 13.1(a). b) Have you ever been refused registration or a licence to trade in or advise on securities or derivatives or both in any province, territory state or country?
Yes No If “Yes”, complete Schedule J, Item 13.1(b). c) Have y ou ev er been d enied the b enefit of any exem ption from registration p rovided i n an y securities o r derivatives or both legislation or rules 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, Item 13.1(c).
d) Are y ou now, or have y ou e ver been subject t o a ny disci plinary pro ceedings or a ny ord er resulting fro m disciplinary p roceedings under a ny secur ities le gislation or derivatives le gislation or b oth i n a ny prov ince, territory, state or country?
Yes No If “Yes”, complete Schedule J, Item 13.1(d). 2. SRO regulation a) Other than an approval that has been recorded under this NRD number, are you now, or have you ever been, an approved person of an SRO or similar organization in any province, territory, state or country?
Yes No If “Yes”, complete Schedule J, Item13.2(a). b) Have you ever been refused approved person status by an SRO or similar organization in any province, territory, state or country?
Yes No If “Yes”, complete Schedule J, Item 13.2(b). c) Are you now, or have y ou ever been, subject to any disciplinary proceedings conducted by any SRO or similar organization in any province, territory, state or country?
Yes No If “Yes”, complete Schedule J, Item 13.2(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 a dvise on securities or derivatives or both in any province, territory, state or country (e.g. insurance, real estate, accountant, lawyer, teacher)?
Yes No If “Yes”, complete Schedule J, Item 13.3(a) b) Have you ever been refused registration or a licence under any legislation relating to your professional activities unrelated to securities or derivatives in any province, territory, state or country?
Yes No If “Yes”, complete Schedule J, Item 13.3(b). c) Are y ou now , or hav e y ou ever be en, a subje ct of a ny disci plinary actio ns co nducted un der any leg islation relating to y our professional activities unrelated to se curities or deri vatives in any province, territory, state or country?
Yes No If “Yes”, complete Schedule J, Item 13.3(c).
Item 14 Criminal disclosure Offences you must disclose You must disclose all criminal offences committed in any province, territory, state or country. This i ncludes, but is not limited to, criminal offences under federal statutes such as th e Criminal Code (Canada), Income Tax Act (Canada), the Competition Act (Canada), Immigration and Refugee Protection Act (Canada) and the Controlled Drugs and Substances Act (Canada) (or its predecessor, the Narcotic Control Act (Canada)). This includes pleas or findings of guilt for impaired driving, w hich are Criminal Code (Canada) m atters. If y ou ha ve been f ound guilty of a criminal offence, y ou m ust disclose the offence even if you have been granted an absolute or conditional discharge.
With respect to questions 14.2 and 14.4, if you or your firm has been found guilty of a criminal offence, or participated in the Al ternative Me asures P rogram within th e past three years, yo u must disclose that offenc e eve n if an absolute or conditional discharge has been granted, or the charge has been dismissed, withdrawn or stayed. Some exceptions apply to stayed charges, and the Alternative Measures Program which are outlined below.
If you do not disclose a criminal offence under any statute other than the former Young Offenders Act (Canada) or the Youth Criminal Justice Act (Canada) , re gulators or, i n Q uébec, t he securi ties r egulatory aut hority or self regul atory organization may treat it as a non-disclosure of material information.
Offences you do not have to disclose The appropriate response is “No” if any of the following circumstances apply. You are not required to disclose: crimes for which you rece ived an absolute or conditi onal discharge if the cr ime has bee n purged from the cri minal records in accordance with the Criminal Records Act (Canada) speeding, parking violations or any offence for w hich a pard on has been granted under the Criminal Records Act (Canada) and the pardon has not been revoked stayed charges for summary conviction offences that have been stayed for six months or more stayed charges for indictable offences that have been stayed for a year or more, and offences under the former Young Offenders Act (Canada) or the Youth Criminal Justice Act (Canada) With respect to questions 14.2 and 14.4, you are not requ ired to disclose an offence for which you or y our firm was found gu ilty i f y ou or the firm participa ted in t he Alt ernative M easures Progra m more than th ree y ears ago for that offence.
1. Are there any outstanding or stayed charges against you alleging a cr iminal offence that was committed in any province, territory, state or country?
Yes No If “Yes”, complete Schedule K, Item 14.1. 2. Have you ever been fo und guilty, pleaded no contest to, or gra nted an absolute or conditional discharge from any criminal offence that was committed in any province, territory, state or country?
Yes No If “Yes”, complete Schedule K, Item 14.2.
3. To the best of your knowledge, are there any outstanding charges against any fi rm of which you were, at the time the criminal 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, Item 14.3. 4. To the best of your knowledge, has any firm, when you were a partner, officer, director or m ajor shareholder, ever been found guilty, pleaded no contest to or granted an absolute or conditional discharge from a crim inal offence that was committed in any province, territory, state or country?
Yes No If “Yes”, complete Schedule K, Item 14.4 . Item 15 Civil disclosure 1. Are there cur rently any outstandi ng c ivil act ions all eging fraud , t heft, d eceit, misrepresentation or sim ilar misconduct against you or a firm where you are or w ere a partner, director, officer or major shareholder in any province, territory, state or country?
Yes No If “Yes”, complete Schedule L, Item 15.1. 2. Have you or a firm where you are or were a partner, director, officer or major shareholder ever been a defendant or respondent in any civil proceeding in which fraud, theft, deceit, misrepresentation or similar misconduct is, or was, successfully established in a judgment in any province, territory, state or country?
Yes No If “Yes”, complete Schedule L, Item 15.2. Item 16 Financial disclosure 1. Bankruptcy Under the laws of any applicable jurisdiction, have you or h as any firm when you w ere a par tner, d irector, officer or major shareholder of that firm:
a) Had a petition in bankruptcy issued or made a voluntary assignment in bankruptcy or any similar proceeding? Yes No If “Yes”, complete Schedule M, Item 16.1(a). b) Made a proposal under any legislation relating to bankruptcy or insolvency or any similar proceeding? Yes No If “Yes”, complete Schedule M, Item 16.1(b).
c) Been subject to proceedings under any legislation relating to the winding up or dissolution of the f irm, or under the Companies’ Creditors Arrangement Act (Canada)?
Yes No If “Yes”, complete Schedule M, Item 16.1(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 regulatory authority, to hold your assets.
Yes No If “Yes”, complete Schedule M, Item 16.1(d). 2. Debt obligations Over the past 10 years, have you failed to meet a financial obligation of $5,000 or more as it came due or, to the best of your knowledge, has any firm, while you were a partner, director, officer or major shareholder of that firm, failed to meet any financial obligation of $5,000 or more as it came due?
Yes No If “Yes”, complete Schedule M, Item 16.2. 3. Surety bond or fidelity bond Have you ever been refused for a surety or fidelity bond? Yes No If “Yes”, complete Schedule M, Item 16.3. 4. Garnishments, unsatisfied judgments or directions to pay Has any federal, provincial, territorial, s tate authority or cour t ever issued any of the fo llowing against you regard ing your indebtedness or, to the best of your knowledge, the indebtedness of a firm where you are or were a partner, director, officer or major shareholder:
Yes No Garnishment
Unsatisfied judgment Direction to pay If “Yes”, complete Schedule M, Item 16.4. Item 17 Ownership of securities and derivatives 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 or both?
Yes No If “Yes”, complete Schedule N.
Item 18 Agent for service By submitting this form, you certify that in each jurisdiction of Canada where you have appointed an agent for service, you have completed the appointment of agent for service required in that jurisdiction.
Item 19 Submission to jurisdiction By submitting this form , you agree t o be subject to the securities legislat ion or derivatives legislation or both of each jurisdiction of Canada, and to th e by-laws, regulations, rules, rulings and policies (collectively referred to as “rules” in this form) of the SROs to which you have submitted this form . This incl udes the jurisd iction o f 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.
Item 20 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 O to administer and enforce c ertain pro visions of t heir securi ties legislation or derivatives legislation or both.
By submitting this form, the individual consents to the collection by the securities regulatory authorities of this personal information, a nd a ny pol ice records, rec ords fro m other gover nment or non- governmental re gulators or SRO s, credi t records and employment records about the individual that the securities regulatory authorities may need to complete their review of the information submitted in this form relating to the individual’s continued fitness for registration or approval, if ap plicable, in accordance wit h t he legal au thority of th e securities re gulatory a uthorities while th e i ndividual is registered wi th or a pproved by it . Secu rities re gulatory authorities may contac t go vernment and private b odies 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 authority in any jurisd iction in whi ch the requ ired information is subm itted. See Schedu le O for detai ls. In Québec, y ou 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.
SROs The principal purpose for the collection of personal information is t o assess your suitability for registr ation or approval and to assess y our continued fitness for registr ation or approval in ac cordance with the ap plicable securities legislation and the rules of the SROs.
By submitting this f orm, you authorize the SROs to wh ich this form is subm itted to collect any information from any source w hatsoever. Th is inc ludes, bu t is not l imited to , pers onal co nfidential i nformation ab out y ou that is o therwise protected by law such as, p olice, credit, employment, education and proficiency course completion records, and records from other g overnment or non-governmental regulatory authorities, securities commissions, st ock exchanges, or other SROs, private bodies, agencies, individuals or corporations, as may be necessary for the SROs to com plete their review of your form or continued fitness for registration or approval in accordance with their rules for the duration of the period you rem ain so reg istered or appr oved. You furt her consent to a nd au thorize t he transfer of c onfidential information between SROs, securities commissions or stock exchanges from whom you now, or may in the future, seek registration or approval, or with which you are currently registered or approved for the purpose of determining fitness or continued fitness f or re gistration or approval or i n c onnection with the p erformance of an i nvestigation or other e xercise of regulatory authority, whether or not you are registered with or approved by them.
By submitting this form , y ou cert ify that you un derstand th e rul es of the a pplicable SROs of whic h y ou ar e seeki ng registration or approval or of which your sponsoring firm is a member or participating organization. You also undertake to become conversa nt w ith the rul es of any SRO s o f w hich y ou or y our sp onsoring firm b ecomes a member o r participating organization. You agree to be bound by, observe and comply with these rules as they are from time to time amended or s upplemented, and y ou ag ree to ke ep yourself fully inform ed ab out t hem as they are am ended and supplemented. You submit to th e jurisdiction of the SROs from whom you are se eking registration or a pproval, or of which y our s ponsoring fir m is now or in t he f uture becomes a member or part icipating or ganization and, wherever applicable, their Governors, Directors and Committees. You agree t hat any registration or a pproval granted pursuant to
this form may be revoked, term inated or suspended at an y tim e in accor dance with t he t hen applic able rules of the respective SR Os. In the event of any su ch rev ocation or term ination, y ou m ust term inate a ll a ctivities wh ich req uire registration or approval and, thereafter, not perform services that require registration or approval for any member of the SROs or any ap proved aff iliated c ompany or other a ffiliate of su ch m ember wi thout o btaining t he ap proval of or registration with the SROs, in accordance with their rules.
By submitting this form, you undertake to notify the SROs from whom you are seeking registration or approval or with which you are currently or may in the fu ture be registered or approved of any material change to the information herein provided in accordance with their respec tive rules. You agree to the transfer of this form, without amendment, to other SROs in the event that at some time in the future you seek registration or approval from such other SROs.
You certify that you have discussed the questions in this form, 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 y ou ful ly und erstood t he q uestions and t he terms of this Agre ement. You f urther c ertify tha t y our business ac tivities that are subject t o sec urities rules a nd derivatives rules or bo th will b e lim ited strict ly t o th ose permitted by the category of your registration or approval.
Item 21 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 22 Certification 1. Certification - NRD format I confirm I have dis cussed the questions in this form with an officer, branch m anager or supervisor of my sponsoring firm. To the best of my knowledge, the officer, branch manager or supervis or 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.
2. Certification - Format other than NRD format Individual By signing below, I certify to the regulator, or in Québec the securities regulatory authority, in each jurisdiction where I am filing or 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. Signature of individual Date
Authorized partner or officer of the firm By signing below, 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, for the individual that:
the individual identified in this form will be engaged by the sponsoring firm as a registered individual or a permitted individual, and 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 and, to the best of my knowledge, 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 Names (Item 1)
Item 1.2 Other personal names Name 1: Last name First name Second name (N/A ) Third name (N/A ) Provide t he r easons for t he use of this name (for exam ple, m arriage, divorce, court order, c ommonly used nam e or nickname)?
When did you use this name? From: _________________ (YYYY/MM) Name 2: _________________________________________________________________________________________________ Last name First name Second name (N/A Provide t he r easons for t he use of this name (for exam ple, m arriage, divorce, court order, c ommonly used nam e or nickname)?
When did you use this name? From: (YYYY/MM) Name 3: Last name First name Second name (N/A Provide t he r easons for t he use of this name (for exam ple, m arriage, divorce, court order, c ommonly used nam e or nickname)? ______________________________________________________________________________________
When did you use this name? From: To: (YYYY/MM) (YYYY/MM) Item 1.3 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 N\A When did you use this name? From: To: _________________ _________________ (YYYY/MM) (YYYY/MM)
To: _________________ (YYYY/MM) ) Third name (N/A )
To: (YYYY/MM) ) Third name (N/A )
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: To: (YYYY/MM) (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: To: (YYYY/MM) (YYYY/MM)
SCHEDULE B Residential address (Item 2)
Item 2.1 Current and previous residential addresses If you have lived at your current address for less than 10 years, list all previous addresses for the past 10 years. You do not have to include a postal code or ZIP code, or a telephone number for any previous address. Address 1: Residential address: (number, street, city, province, territory or state, country)
When did you live at this address? From: To: (YYYY/MM) (YYYY/MM) Address 2: Residential address: (number, street, city, province, territory or state, country)
When did you live at this address? From: To: (YYYY/MM) (YYYY/MM) Address 3: Residential address: (number, street, city, province, territory or state, country)
When did you live at this address? From: (YYYY/MM)
To: (YYYY/MM)
SCHEDULE C Individual Categories (Item 6)
Check each category for which you are seeking registration, approval or review as a permitted individual. 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 [ ] 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 [ ] Trader
Additional approval categories [ ] Chief Compliance Officer [ ] Chief Financial Officer [ ] Ultimate Designated Person 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 Trader [ ] Salesperson [ ] Branch Manager [ ] Adviser [ ] Officer – Specify title: [ ] Director [ ] Partner [ ] Futures Contracts Portfolio Manager [ ] Associate Futures Contracts Portfolio Manager [ ] IIROC approval only [ ] Local
Québec - activities relating to derivatives For information purposes, indicate whether you will carry on activities as a representative of: [ ] An Investment Dealer Acting as a Derivatives Dealer [ ] A Portfolio Manager Acting as a Derivatives Portfolio Manager
SCHEDULE D Address and agent for service (Item 7)
Item 7.1 Address for service You must have one address for service in each province or t erritory 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: (___) E-mail address: Item 7.2 Agent for service If you have appointed an agent for s ervice, provide the following information about 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
SCHEDULE E Proficiency (Item 8)
Item 8.1 Course, examination or designation information and other education Date completed Course, examination, designation or other (YYYY/MM/DD) education If you have listed the CFA Charter in Item 8.1, please indicate by checking the box below whether you are a current member of the CFA Institute permitted to use the CFA Charter.
Yes No If “no”, please explain why you no longer hold this designation: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
If you have listed the CIM designation in Item 8.1, please indicate by checking the box below whether you are currently permitted to use the CIM designation.
Yes No If “no”, please explain why you no longer hold this designation: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
Date exempted Regulator / securities (YYYY/MM/DD) regulatory authority granting the exemption
SCHEDULE F Proficiency (Items 8.3 and 8.4)
Item 8.3 Exemption refusal Complete the following for each exemption that was refused. 1. Which securities regulator, derivatives regulator or SRO refused to grant the exemption?
State the name of the course, examination, designation or experience requirement: State the reason given for not being granted the exemption: Date exemption refused: _________________________________ (YYY Y/MM/DD) 2. Which securities regulator, derivatives regulator or SRO refused to grant the exemption? State the name of the course, examination, designation or experience requirement: State the reason given for not being granted the exemption: Date exemption refused: (YYY Y/MM/DD) 3. Which securities regulator, derivatives regulator or SRO refused to grant the exemption? State the name of the course, examination, designation or experience requirement: State the reason given for not being granted the exemption: Date exemption refused: (YYY Y/MM/DD)
Item 8.4 Relevant securities industry experience 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 G Current employment, other business activities, officer positions held and directorships (Item 10)
Complete a separate Schedule G for each of your current business and employment activities with your sponsoring firm and w ith a ll other orga nizations. T his i ncludes any business related offic er or direc tor p ositions h eld, or any ot her equivalent positions held, whether you receive compensation or not.
1. Start date ___________________________ (YYY Y/MM/DD) 2. Firm information Check here if this activity is employment with your sponsoring firm. If the act ivity is w ith y our spons oring fi rm, you are n ot req uired t o ind icate t he firm nam e an d ad dress inf ormation 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 duties Describe all employment and business activities re lated to this employer. Inc lude the na ture of the business and your duties, title or relationship with the business. If y ou a re seeking registration that requires s pecific experience, include details wi th th is fi rm su ch a s level o f re sponsibility, value of accounts u nder d irect s upervision, n umber of y ears of experience, and percentage of time spent on each activity.
4. Number of work hours per week How many hours per week do you devote to this business or employment? If this activity is employment with your sponsoring firm and you work less than 30 hours per week, explain why.
5. Conflicts of interest If you have more than one employer or are engaged in business related activities: A. Disclose a ny potential for confusion by clients and any potential for conflic ts of inter est arising from your multiple employment or business related activities or proposed business related activities.
_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
B. Indicate whether or not any of y our employers or o rganizations where you engage in business related activities are listed on an exchange.
_________________________________________________________________________________________________
C. Confirm whether the firm has procedures for minimizing potential conflicts of interest and if so, confirm that you are aware of these procedures.
_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
D. State the name of the person at your sponsoring firm who has re viewed and approved your multiple employment or business related activities or proposed business related activities
__________________________________________________ E. If you do not perceive any conflicts of interest arising from this employment, explain why.
SCHEDULE H Previous employment and other activities (Item 11)
Provide the following information for each of your employment and other activities in the past 10-years. Account for all of your time, including full-time and part-time employment, self-employment or military service. Include your status for each, such as unemployed, full-time student, or ot her si milar statuses. Do not i nclude short-te rm e mployment of four months or less while a student, unless it was in the securities, derivatives or financial industry.
In addition to the information required in the paragraph above, if y ou were employed or h ad business activities in the securities or derivatives industry or both during and before the 10-year period, disclose all your securities and derivatives or both employment or business activities (both before and during the 10-year period).
Unemployed Full-time student Employed or self-employed
From: (YYY Y/MM) To: (YYY Y/MM) Complete the following only if you are, or were, employed or self-employed during this period. 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 fir m. If y ou are seeking registration in a category of re gistration that requires s pecific experience, include details of that experience. Examples include level of responsibility, value of a ccounts under direct supervision, number of years of that experience and research experience, and percentage of time spent on each activity.
Reason why you left the firm:
SCHEDULE I Resignations and terminations (Item 12)
Item 12.1 For each allegation of violation of any statutes, regulations, rules or internal/external standards of conduct, state below (1) t he name of the fi rm from which you resigned, were terminated or dismissed for cause, (2) whether you resigned, were terminated or dismissed for c ause, (3) the date you resigned, were terminated or dismissed for cause, and (4) the circumstances relating to your resignation, termination or dismissal for cause.
Item 12.2 For each al legation of fai lure t o supervise c ompliance with any st atutes, re gulations, rul es or standards of conduct, state below, (1) the name of the firm from which you resigned, were terminated or dismissed for cause, (2) whether you resigned, were terminated or dismissed for cause, (3) the date you resigned, were terminated or dismissed for cause, and (4) the circumstances relating to your resignation, termination or dismissal for cause.
Item 12.3 For each allegation of fraud or the wrongful taking of property, including theft, state below (1) the name of the firm fro m whic h y ou resi gned, w ere t erminated or dismissed for cause, (2) whether y ou resign ed, w ere terminated or dismissed for cause, (3) the date you resigned, were terminated or dismissed for cause, and (4) the circumstances relating to your resignation, termination or dismissal for cause.
SCHEDULE J Regulatory disclosure (Item 13)
Item 13.1 Securities and derivatives regulation a) For each registration or licence, state below (1) th e name of the firm, (2) the securities or derivatives regulator with which you are, or were, registered or licensed, (3) the type or category of registration or licence, and (4) the period that you held the registration or licence.
b) For each re gistration or licence refused, state below (1) the nam e of the firm , (2) the securities or derivatives regulator that refused the registration or licence, (3) the type or category of registra tion or licence refused, (4) the date of the refusal, and (5) the reasons for the refusal.
c) For each exemption from registration denied or licence refused, other than what was disclosed in Item 8(3) of this form, state below (1) the party that was refused the exemption from registration or licence, (2) the securities or der ivatives regu lator that refuse d the exemption fro m registrati on or l icence, ( 3) t he type or cate gory or registration or licence refused, (4) the date of the refusal, and (5) the reasons for the refusal.
d) For each order or disciplinary proceeding, state below (1) the name of the firm , (2) the securities or derivatives regulator th at issue d th e o rder or is c onducting or c onducted th e proce eding, (3) the date any no tice of proceeding was issued, (4) the date any order or set tlement was made, (5) a sum mary of any not ice, order or settlement (including any sanctions imposed), (6) w hether you are or were a part ner, director, officer or major shareholder of the firm an d nam ed indi vidually in the order or di sciplinary pr oceeding, a nd (7) any ot her relevant details.
Item 13.2 SRO regulation a) For each approval, state below (1) the name of the fi rm, (2) the SRO with whic h you are or were an approved person, (3) the categories of approval, and (4) the period that you held the approval.
b) For each approval refused, state below (1) the name of the firm, (2) the SRO that refused the approval, (3) t he category of approval refused, (4) the date of the refusal, and (5) the reasons for the refusal.
c) For each order or disciplinary proceeding, state below (1) the name of the firm, (2) the SRO that issued the order or that is, or was, conducting the proceeding, (3) the d ate any notice of proceeding was issued, (4) the date any order or set tlement w as made, (5) a s ummary of any notic e, or der or settl ement (i ncluding any sanct ions imposed), (6) whether you are or were a partner, director, officer or major shareholder of the firm and n amed individually in the order or disciplinary proceeding, and (7) any other information that you think is rel evant or that the regulator or, in Québec, the securities regulatory authority may request.
Item 13.3 Non-securities regulation a) For each registration or licence, st ate be low (1) the pa rty wh o is, or was, regi stered or li censed (if insurance licensed, a lso ind icate the name of the i nsurance agency), (2) with which regulatory authority, or un der what legislation, the party is, or was, registered or licensed, (3) the type or category of registration or licence, and (4) the period that the party held the registration or licence.
b) For each regi stration or li cence refused, state below (1) the party that was refused registra tion or licensing (if insurance li censed, als o i ndicate t he name of t he insurance ag ency), (2) w ith w hich re gulatory aut hority, or under what legislation, the registration or licence was refused, (3) the type or category of registration or licence 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 (if insurance licensed, indicate the name of the insurance agency), (2) the regulatory author ity 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 set tlement w as made, (5) a s ummary of any notic e, or der or settl ement (i ncluding any sanct ions imposed), (6) whether you are or were a partner, director, officer or major shareholder of the firm and n amed individually in the order or disciplinary proceeding and (7) a ny other information that you think is rele vant or that the regulatory authority may request.
SCHEDULE K Criminal disclosure (Item 14) Item 14.1
For each charge, state below (1) the type of charge, (2) the date of the charge, (3) any trial or appeal dates, and (4) the court location.
Item 14.2 For each fi nding of gui lty, pleading no contest to, or granting of a n absolute or c onditional discharge from a criminal offence state below (1) the offe nce, (2) the date found guilty, and (3) th e disposition (any penalty or fine and the date any fine was paid).
Item 14.3 For each charge, state 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.
Item 14.4 For each fi nding of gui lty, pleading no contest to, or granting of a n absolute or c onditional discharge from a criminal offence state below (1) the name of the firm, (2) the offence, (3) the date of the conviction, and (4) the disposition (any penalty or fine and the date any fine was paid).
SCHEDULE L Civil disclosure (Item 15)
Item 15.1 For each outstanding civil proceeding, state below (1) the dates the statement of claim and statement of defence were issued , (2) the name of the plaintiff(s) in the pr oceeding, (3) w hether the proceeding is pending or o n appeal, (4) w hether t he proceeding was against a firm wher e you a re, or were, a part ner, director, officer or major shareho lder an d w hether y ou ha ve been named indi vidually in the al legations, an d (5) th e jurisd iction where the action is being pursued.
Item 15.2 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 proceeding was about a fi rm 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. You must disclose any actions settled without admission of liability.
SCHEDULE M Financial Disclosure (Item 16)
Item 16.1 Bankruptcy (a) For each event, sta te below (1) the da te of the petition or vo luntary assignment, (2) the person or firm about whom this d isclosure is being made, (3) any amounts currently owing, (4) the creditors, (5) t he sta tus 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 the regulator or, in Québec, the securities regulatory authority may request.
(b) For each event, state below (1) t he date of the proposal, (2) the person or firm about whom this d isclosure is being made, (3) any amounts currently owing, (4) t he creditors, (5) the st atus of the matter, (6) a su mmary of any disposition or settlement, and (7) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.
(c) For each event, state below (1) the date of the proceeding, (2) the person or firm about whom this disclosure is being made, (3) any amounts currently owing, (4) t he creditors, (5) the st atus of the matter, (6) a su mmary of any disposition or settlement, and (7) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.
(d) For each proceeding, arrangement or compromise with creditors, state below (1) the date of proceeding, (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 su mmary of any disposition or se ttlement, and (7) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.
Item 16.2 Debt obligation For each e vent, state below (1) the perso n or firm that failed t o meet its fina ncial obligation, (2) the am ount 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 the regulator or, in Québec, the securities regulatory authority may request, including why obligation has not been met/satisfied.
Item 16.3 Surety bond or fidelity bond For each bond refuse d, state below (1) t he 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.
Item 16.4 Garnishments, unsatisfied judgments or directions to pay For eac h garnishment, unsatisfied judgment or direction to pay r egarding y our in debtedness, in dicate below (1) th e amount that was owing at the time the garnishment, judgment 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 garnished or the amount to be paid, (5) any amounts currently owing, and (6) any other information that you think is relevant or that the regulator or, in Québec, the securities regulatory authority may request.
SCHEDULE N Ownership of securities and derivatives firms (Item 17)
Firm name: What is your relationship to the firm? Partner Major shareholder What is the period of this relationship? From: To: (if applicable) (YYY Y/MM) (YYY Y/MM) Provide the following information: a) State the number, va lue, cl ass and per centage of sec urities, or t he amount of pa rtnership in terest you own or propose to acquire when you are registered or approved as a result of the review of this form. If acquiring shares when you are so approved or registered, st ate the source (for example, treasury shares, or if upon transfer, state name of transferor).
b) State the market va lue (approximate, if necess ary) of any subordina ted 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) If another person or firm has provided you with funds to i nvest in the firm, provide the name of the p erson 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”, provide the name of the person or firm and state the relationship between you and that person or firm:
e) Have you directly or indirectly given up any rights relating to these securities or this partnership interest, or do you, when you are registere d or approve d as a resul t of the review of this form , intend to give up any of t hese rights (including by hypothecation, pledging or depositing as collateral the securities or partnership interest with any firm or person)?
Yes No If “Yes”, provide the name of 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:
f) 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).
g) Name of beneficial owner: Last name First name Secon d name Third name (if applicable) (if applicable) h) Residential address: (number, street, city, province, territory or state, country, postal code) i) Occup ation:
Schedule O 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