FORM 33-109F2 CHANGE OR SURRENDER OF INDIVIDUAL CATEGORIES Enter the following information using the online version of this submission at the NRD web site (www.nrd.ca). If the NRD filer is relying on the temporary hardship exemption in MI 31-102 this form is required to be delivered to the regulator in paper format. 1. Individual Name of individual: NRD number of individual: 2. Individual categories Indicate the individual categories that the individual is adding or removing: 3. Details of surrender If the individual is surrendering his or her registration include details regarding any: • unresolved client complaints: • internal discipline matters: • restrictions for violation of regulatory requirements that occurred at any time during the individual’s employment with the firm: • financial obligations the individual has to clients: Notice of Collection and Use of Personal Information The personal information required under this form is collected on behalf of and used by the securities regulatory authorities set out below for the administration and enforcement of certain provisions of the securities legislation in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, New Brunswick, Prince Edward Island, Newfoundland and Labrador, Northwest Territories, Yukon Territory, and Nunavut. By submitting this information you consent to the collection by the securities regulatory authority of the personal information provided above, police records, records from other government or non-governmental regulatory authorities or self-regulatory organizations, credit records and employment records about you as may be necessary for the securities regulatory authority to complete its review of the information submitted above including your continued fitness for registration, if applicable, in accordance with the legal authority of the securities regulatory authority for the duration of the period which you remain registered or approved by the securities regulatory authority. The sources the securities regulatory authority may contact include government and private bodies or agencies, individuals, corporations and other organizations.
If you have any questions about the collection and use of this information, you may contact the securities regulatory authority in any jurisdiction in which the required information is filed, at the address or telephone number provided in Schedule “A”. WARNING: It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue. CERTIFICATION: The following certification is to be used when submitting this form in NRD format: I am making this submission as agent for the individual to whom this submission relates. By checking this box I certify that all statements of fact in this submission were provided to me by the individual. Both of the following certifications are to be used when submitting this form in paper format: I, the undersigned, certify that I have read and that I understand the questions in this form and the Warning set out above. I also certify that all statements of fact provided in this application are true. Signature of applicant or non-registered individual Date I, the undersigned, certify on behalf of the sponsoring firm that the individual will be engaged by the sponsoring firm as a registered individual or a non-registered individual. I certify that I have, or a branch manager or another officer or partner has, discussed the questions set out in this form and I am satisfied that the individual fully understands the questions. Signature of authorized officer or partner Date ________________________________________________ Firm name
SCHEDULE “A” Notice and collection and use of 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 Manitoba The Manitoba Securities Commission 1130-405 Broadway Winnipeg, MB R3C 3L6 Attention: Director - Legal Telephone: (204) 945-0605 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 Northwest Territories Government of the Northwest Territories P.O. Box 1320 Yellowknife, NWT X1A 2L9 Attention: Deputy Registrar of Securities Telephone: (867) 920-8984 Ontario Ontario Securities Commission Suite 1903, Box 55 20 Queen Street West Toronto, ON M5H 3S8 Attention: FOI Coordinator Telephone: (416) 593-8314 Québec Commission des valeurs mobilières du Québec 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) 940-2150 or (800) 361-5072 (in Québec) Yukon Department of Community Services Yukon P.O. Box 2703 Whitehorse, YU Y1A 2C6 Attention: Registrar of Securities Telephone: (867) 667-5225British 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) New Brunswick Securities Administration Branch PO Box 5001 606, 133 Prince William Street Saint John, NB E2L 4Y9 Attention: Deputy Administrator, Capital Markets Telephone: (506) 658-3021 Nova Scotia Nova Scotia Securities Commission 2 nd Floor, Joseph Howe Building 1690 Hollis Street P.O. Box 458 Halifax, NS B3J 3J9 Attention: FOI Officer Telephone: (902) 424-7768 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 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 Saskatchewan Saskatchewan Securities Commission 800 B1920 Broad Street Regina, SK S4P 3V7 Attention: Director Telephone: (306) 787-5842
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.