33-109F5 - Change Of Registration Information [Proposed F - Lapsed]

FORM 33-109F5

CHANGE OF REGISTRATION INFORMATION

GENERAL INSTRUCTIONS

1. This notice must be submitted in accordance with MI 33-109.
2. All questions must be answered. Failure to do so may cause delays in the processing of the notice.
3. All attachments pertaining to any questions must be made exhibits to the form and each one must be so marked.
4. This form and all attachments added thereto must be legible.

1. Type of form
   
   Complete the following to identify the part of the Form 3 or Form 33-109F4 for which this notice is being provided. If this notice is being provided to update an individual’s Form 33-109F4, provide the name of the individual.
   
   Form 3, Item ,or
   
   Form 33-109F4 , Item .
   
   Name of individual:
   
   
2. Current information
   
   Provide the current information for that part of the form identified above:
   
   List supporting documents (if any):
   
   

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 purposes of 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, 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 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.

The principal purpose for which this collection of personal information is to be used is to assess your continued fitness for registration, if applicable, in accordance with the applicable securities legislation.

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 set out below.

(In the final draft of the form a list of contact information will be included here.)

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

I, the undersigned, certify that I have read and that I understand the questions in this notice and the Warning set out above.

I also certify that all statements of fact made in the answers to the questions are true.

Dated this ___________________ day of _________________, 200 __________.

Name of individual (if applicable):

Signature of individual:

OR

Name of firm (if applicable):

Authorized signature:

Print name:

Title: