FORM 33-109F2 CHANGE OR SURRENDER OF INDIVIDUAL CATEGORIES (section 4.2 or 2.2(2) or 2.5(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 individual seeks to add and/or remove 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 relying on the temporary hardship exemption in section 5.1 of National 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? Only choose “no” if you are registered in: (a) only one jurisdiction of Canada, or (b) more than one jurisdiction of Canada and you are requesting a change or surrender: (i) in a non-principal jurisdiction or jurisdictions, but not 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. What categories are you seeking to add? 2. 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 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 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. 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 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 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.