FORM 33-109F5 CHANGE OF REGISTRATION INFORMATION (sections 3.1 and 4.1 ) GENERAL INSTRUCTIONS Complete a nd su bmit th is form to no tify the rel evant re gulator(s) or, in Qué bec, t he se curities regulatory authority, or se lf-regulatory organization (SRO) of changes to infor mation in the following forms: 1. Form 33-109F6, except for the changes set out in section 3.1 of National Instrument 33-109, or 2. Form 33-109F4. How to submit this form To report c hanges to information in a F orm 33-109F4, submit this form at the N ational Registration Database website in NRD format at www.nrd.ca. Submit this form in a format other than NRD format to report changes to information in a: a) Form 33-109F6, or b) Form 33-109F4, if the individual is relying on the temporary hardship exemption in 5.1 of National Instrument 31-102 [National Registration Database]. Name of firm Registration categories NRD number (firm) ___________________________________ Item 1 Type of form Check the form that is being updated: Form 33-109F6 If subm itting changes t o F orm 33-10 9F6, please attach a blackline of the am ended sec tions of t he form. Form 33-109F4 Name of individual __________________________________ Item 2 Details of change Provide the item number and details for each change to the form selected above: Item number _______ Details _____________________________________________________________ Effective date of change __________________________________ (YYY Y/MM/DD)
Item 3 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 aut horities in the juris dictions set o ut in S chedule A t o adm inister a nd e nforce ce rtain 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 sub mitting th is form , the i ndividual conse nts to the c ollection by th e sec urities reg ulatory authorities or applicable SRO of this personal information, and any police records, records from other government or non-governmental regulators or SRO s, credi t records and employment records about the individual that the securities regulatory authorities or applicable SRO may need to complete their review of th e inform ation submitted i n this f orm relatin g t o t he individual’s continued fi tness for registration o r approv al, if appl icable, i n acc ordance with the l egal a uthority of the sec urities regulatory authorities while the individual is re gistered 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 y ou ha ve a ny qu estions about th e c ollection a nd use of this i nformation, contact the se curities regulatory au thorities or applicable SRO in a ny jur isdiction in wh ich t he re quired information is submitted. Se e Schedul e A for detai ls. In Québec, you can also c ontact t he Comm ission d’a ccès à l’information at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca. Item 4 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 5 Certification 1. Use the following certification when submitting this form in NRD format when making changes to Form 33-109F4 I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm . To t he b est of my know ledge and be lief, t he offi cer, branch m anager or supervisor wa s satisfie d th at I fully u nderstood the questions. I will lim it my acti vities 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. 2. Use the following certification when submitting this form in a format other than NRD format when making changes to Form 33-109F6 By signing below I certify to each 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.
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) 3. Use the following certification when submitting this form in a format other than NRD format under the temporary hardship exemption in section 5.1 of NI 31-102 when making changes to Form 33-109F4 By signing below, I certify to t he regulator or, in Q uébec, 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. Signature of individual ___________________________________ Date signed ________________________ (YYYY/MM/DD)
Schedule A 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 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 Gene ral B Consum er, Corporat e 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: (51 4) 395- 0337 or (87 7) 525-0 337 (i n Québec) Saskatchewan Saskatchewan Financial Services Commission Suite 601, 1919 Saskatchewan Drive Regina, SK S4P 4H2 Attention: Director Telephone: (306) 787-5842
Northwest Territories Yukon Government of the Northwest Territories Yukon Securities Office P.O. Box 1320 Department of Community Services Yellowknife, NWT X1A 2L9 P.O. Box 2703 C-6 Attention: Deputy Superintendent of Securities Whitehorse, YT Y1A 2C6 Telephone: (867) 920-8984 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.