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 form to notify the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-
regulatory organization (SRO) that a registered individual or permitted individual seeks to add and/or remove individual
registration categories or permitted activities or provide notice of other changes to the information on Schedule C of Form 33-
109F4.
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 relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration
Database, 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 of Canada
(b)
more than one jurisdiction of Canada and you are requesting a surrender in a non-principal jurisdiction or
jurisdictions, but not in your principal jurisdiction, or
(c)
more than one jurisdiction of 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.
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 scholarship 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 “N/A”.
If “Yes”, complete Schedule A.
Item 5 Reason for surrender
If you are seeking to remove a registration 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 required under this form is collected on behalf of, and used by, the securities regulatory authorities in
the jurisdictions set out in Schedule B to administer and enforce certain provisions of their securities legislation or derivatives
legislation or both.
The personal information required under this form is also collected by and used by the SRO set out in Schedule B to administer
and enforce its by-laws, regulations, rules, rulings and policies.
By submitting this form, the individual consents to the collection by the securities regulatory authorities or applicable SRO of this
personal information, and any police records, records from other government or non-governmental regulators or SROs, credit
records and employment records about the individual that the securities regulatory authorities or applicable SRO 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 applicable, in accordance with the legal 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 B 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.
Item 7
Warning
It is an offence under securities legislation and 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 checking 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 _________________
(YYYY/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 ________________________________________
____________________________________ (YYYY/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 the continuing education activities in which you have participated during the last 36 months and that 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) 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 Canada)
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
Financial and Consumer Services Commission of New
Brunswick / Commission des services financiers et des
services aux consommateurs du Nouveau-Brunswick
Suite 300, 85 Charlotte Street
Saint John, NB E2L 2J2
Attention: Director of Securities
Telephone: (506) 658-3060
Newfoundland and Labrador
Superintendent of Securities, Service NL
Government of Newfoundland and Labrador
P.O. Box 8700
2nd Floor, West Block
Confederation Building
St. John's, NL A1B 4J6
Attention: Manager of Registrations
Telephone: (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
Department of Justice
1
st
Floor Stuart M. Hodgson Building
5009 – 49
th
Street
Yellowknife, NWT X1A 2L9
Attention: Deputy Superintendent of Securities
Telephone: (867) 920-8984
Nunavut
Government of Nunavut
Department of Justice
P.O. Box 1000 Station 570
Iqaluit, NU X0A 0H0
Attention: Deputy Registrar of Securities
Telephone: (867) 975-6590
Ontario
Ontario Securities Commission
22
nd
Floor
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 Office
Department of Community Affairs and Attorney General
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
Saskatchewan
Financial and Consumer Affairs Authority of Saskatchewan
Suite 601, 1919 Saskatchewan Drive
Regina, SK S4P 4H2
Attention: Deputy Director, Capital Markets
Telephone: (306) 787-5871
Yukon
Government of Yukon
Superintendent of Securities
Department of Community Services
P.O. Box 2703 C-6
Whitehorse, YT Y1A 2C6
Attention: Superintendent of Securities
Telephone: (867) 667-5314
Self-regulatory organization
Investment Industry Regulatory Organization of Canada
121 King Street West, Suite 2000
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.