FORM 33-109F1 NOTICE OF TERMINATION OF REGISTERED INDIVIDUALS AND PERMITTED INDIVIDUALS (section 4.2) 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 person has left their sponsoring firm. Terms In this form, “cessation date” (or “effective date of termination”) means the first day on which an individual ceased to have authority to act as a registered individual on behalf of their sponsoring firm or ceased to be a permitted individual of their sponsoring firm, because of the end of, or a change in, the individual’s employment, partnership, or agency relationship with the firm; How to submit the 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. When to submit the form You must submit the responses to Item 1, Item 2, Item 3 and Item 4 within five business days of the effective date of termination. If you are required to complete Item 5, you must submit those responses within 30 days of the termination date. If you are submitting the responses to Item 5, in NRD format, after Items 1 to 4 have been submitted at NRD, use the NRD submission type called “Update/Correct Termination Information” to complete Item 5 of this form. Item 1 Terminating firm 1. Name 2. NRD number Item 2 Terminated individual 1. Name 2. NRD number Item 3 Business location of the terminated individual 1. Address 2. NRD number Item 4 Date and reason for termination 1. Cessation date / Effective date of termination ______ (YYYY/MM/DD) This is the first day that the individual ceased to have authority to act in a registerable capacity on behalf of the firm or ceased to be a permitted individual.
2. Reason for termination / cessation (check one): Resigned - voluntary Resigned - at the firm’s request Dismissed in good standing Dismissed for cause Completed temporary employment contract Retired Deceased Other Item 5 Details about the termination Complete Item 5 only if the individual resigned, was dismissed (whether or not for cause), or if the reason for termination under Item 4.2 was “Other”. In the space below: • state the reason(s) for the resignation, dismissal or “Other” reason for termination and • provide details if the answer to any of the following questions is “Yes”. [For NRD Format only:] This information will be disclosed within 30 days of the effective date of termination Not applicable: completed temporary employment contract, retired or deceased Answer the following questions to the best of the firm’s knowledge. In the past 12 months: Yes No 1. Was the individual charged with any criminal offence? 2. Was the individual the subject of any investigation by any securities or financial industry regulator? 3. Was the individual subject to any significant internal disciplinary measures at the firm or at any affiliate of the firm related to the individual’s activity as a registrant? 4. Were there any written complaints, civil claims and/or arbitration notices filed against the individual or against the firm about the individual’s securities-related activities that occurred while the individual was registered or a permitted individual authorized to act on behalf of the firm? 5. Does the individual have any undischarged financial obligations to clients of the firm? 6. Has the firm or any affiliate of the firm suffered significant monetary loss or harm to its reputation as a result of the individual’s actions?
7. Did the firm or any affiliate of the firm investigate the individual relating to possible material violations of fiduciary duties, regulatory requirements or the compliance policies and procedures of the firm or any affiliate of the firm? Examples include making unsuitable trades or investment recommendations, stealing or borrowing client money or securities, hiding losses from clients, forging client signatures, money laundering, deliberately making false representations and engaging in undisclosed outside business activity. 8. Did the individual repeatedly fail to follow compliance policies and procedures of the firm or any affiliate of the firm? 9. Did the individual engage in discretionary management of client accounts or otherwise engage in registerable activity without appropriate registration or without the firm’s authorization? Reasons/Details: 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 A 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 SROs set out in Schedule A to administer and enforce their respective 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 as the case may be. 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 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/or derivatives legislation, including commodity futures legislation to give false or misleading information on this form. Item 8 Certification Certification-NRD format: I am making this submission as agent for the firm. By checking this box, I certify that the firm provided me with all of the information on this form.
Certification-Format other than NRD format: 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 firm, 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. 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 Contact information for Notice of collection and use of personal information Alberta Alberta Securities Commission, 4th Floor, 300 - 5th Avenue SW Calgary, AB T2P 3C4 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 2nd Floor, Joseph Howe Building 1690 Hollis Street P.O. Box 458 Halifax, NS B3J 2P8 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: FOI Coordinator Telephone: (416) 593-8314 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.