Form 4 - Uniform application for registration / approval (BC) [F - Rescinded]
| Published Date: | 1997-01-03 |
|---|---|
| Effective Date: | 1997-01-31 |
| Rescinded Date: | 1998-07-22 |
FORM 4
Uniform application for registration / approval (BC)
FOR INTERNAL USE ONLY
DATE _______________________
DISCLOSURE o YES o NO
FOREIGN ENQUIRY o
UPDATE o __________________
______________________________
Freedom of Information and Protection of Privacy Act
The personal information requested on this form is collected under the authority of and used for the purpose of administering the Securities Act.Questions about the collection or use of this information can be directed to the Supervisor, Registration, British Columbia Securities Commission, 200 - 865 Hornby Street, Vancouver, British Columbia V6Z 2H4. Telephone (604) 899-6692. Toll Free within British Columbia 1-800-373-6393.
INSTRUCTIONS
1 . This form is to be used by every individual seeking registration or approval from a Canadian Securities Commission or similar authority and/or a self-regulatory organization, or submitting an application for registration or approval as a partner, director or officer of a dealer, adviser or underwriter to a Canadian Securities Commission or similar authority.
2. This form may also be used by any individual submitting an application for registration as a dealer, or adviser to a Canadian Securities Commission or similar authority.
3. All applicable questions must be answered. Failure to do so may cause delays in the processing of the application.
4. This form and all attachments added thereto must be typewritten, printed legibly in ink or prepared on an approved computer-generated form. Any form or attachment completed by any other means may be considered not properly filed.
5. All attachments pertaining to any question must be made exhibits to the form and each one must be so marked. All signatures must be originals. The Commissioner of Oaths before whom the application is sworn, as well as the applicant, is required to initial all attachments.
6. In completing the application, applicants should seek advice from an authorized officer of the sponsoring firm or from a legal adviser, if necessary.
7. Number of originally-signed copies of the form to be filed with the self-regulatory organization and/or Securities Commission or similar authority varies from province to province. If unsure of the procedure, please consult the Registration Department of the self-regulatory organization through which you are applying or the applicable Securities Commission, or similar authority.
8. Applicants for registration in Quebec need only disclose information for the past 10 years in respect of Questions 15B, 15D, 17A, 17B, 18 and 19.
9. This form has been modified to conform with amendments to securities legislation in British Columbia. If you wish to file this form other than with the British Columbia Securities Commission please contact the self-regulatory organization and/or Securities Regulatory Authority prior to filing with them.
________________________________________________________________________
FOR INTERNAL USE ONLY ________________
APPLICATION APPROVED BY DATE
Y M D
___ ___ ___
________________________________________
________________________________________________________________________
1. APPLICANT
LAST NAME FIRST, SECOND AND THIRD NAMES - if applicable
________________________________________________________________________
RESIDENTIAL ADDRESS POSTAL CODE
________________________________________________________________________
TELEPHONE NUMBER FAX NUMBER
(AREA CODE) (AREA CODE)
________________________________________________________________________
EMAIL/INTERNET ADDRESS SOCIAL INSURANCE NUMBER
(Not required for applications in Ontario)
________________________________________________________________________
ADDRESS FOR SERVICE IN BRITISH COLUMBIA POSTAL CODE
________________________________________________________________________
PRESENT POSITION IN THE FIRM COMMENCED EMPLOYMENT ON
Y M D
___ ___ ___
________________________________________________________________________
2. FIRM
NAME
________________________________________________________________________
TELEPHONE NUMBER FAX NUMBER EMAIL/INTERNET ADDRESS
(AREA CODE) (AREA CODE)
________________________________________________________________________
ADDRESS WHERE APPLICANT WILL BE WORKING POSTAL CODE
________________________________________________________________________
3. TYPE OF REGISTRATION OR APPROVAL REQUESTED
INSTRUCTION: Check ALL applicable boxes to indicate the registration or approval requested. The "Types of Registration or Approval Requested" have the meaning attributed to them in the applicable securities act or regulation and in by-laws, rules and regulations of exchanges, the Investment Dealers Association of Canada and otherself-regulatoryorganizations.
| TYPE OF INSTRUMENTS TYPE OF REGISTRATION | |
| o Securities (Other than Forward Contracts) | o Salesperson |
| o Exchange Contracts | o Partner |
| o Forward Contracts | o Director |
| o Mutual Fund Securities | o Officer(title) ________________________ |
o Scholarship Plan Securities | -Trading/Advising o |
| o Real Estate Securities | - Non-Trading/Advising o |
o Security Issuer Securities | -ComplianceOfficer o |
| o Other (specify) ________________________ | o Branch Manager |
| o Director, Investor, or officer of approved affiliated company (delete designation not applicable) | |
| o Industry Investor | |
| o Non-Industrylnvestor | |
| o Portfolio Manager | |
| o InvestmentCounsel | |
o Securities Adviser | |
| o Advising Employee | |
| o Other (specify) ________________________ | |
4. APPLYING FOR REGISTRATION / APPROVAL FROM THE FOLLOWING
INSTRUCTION: Check all appropriate boxes to indicate the Canadian Securities Commissions or similar authority and/or self-regulatory organizations with which the applicant is seeking registration or approval.
| SECURITIES COMMISSIONS OR SIMILAR AUTHORITIES | |||
| o Alberta | o New Brunswick | o Nova Scotia | o Quebec |
o British Columbia | o Newfoundland | o Ontario | o Saskatchewan |
| o Manitoba | o Northwest Territories | o Prince Edward Island | o Yukon Territory |
| SELF-REGULATORYORGANIZATIONS | |
| o Alberta Stock Exchange | o The Toronto Stock Exchange |
| o Investment Dealers Association of Canada | o Vancouver Stock Exchange |
| o Montreal Exchange | o Winnipeg Commodity Exchange |
o Toronto Futures Exchange | o Winnipeg Stock Exchange |
| o Other (specify) ________________________ | |
5. PERSONAL DESCRIPTION OF APPLICANT
________________________________________________________________________
DATE OF BIRTH PLACE OF BIRTH GENDER
Y M D CITY PROVINCE COUNTRY o MALE o FEMALE
___ ___ ___
________________________________________________________________________
HEIGHT WEIGHT COLOUR OF EYES COLOUR OF HAIR NAME OF SPOUSE AND NATURE
OF HIS / HER EMPLOYMENT
______________________________________________________
CITIZENSHIP
________________________________________________________________________
If NOT a Canadian Citizen, answer the following
ARE YOU A NUMBER OF YEARS OF CONTINUOUS
PERMANENT RESIDENT? RESIDENCE IN CANADA
o YES o NO
________________________________________________________________________
PASSPORT INFORMATION
COUNTRY PLACE OF ISSUE DATE OF ISSUE PASSPORT NUMBER
Y M D
___ ___ ___
________________________________________________________________________
6. PHOTOGRAPH
INSTRUCTION: Attach hereto two copies of a photograph, full face, showing a true likeness of the applicant as the applicant now appears and taken within the last 6 months; they must measure 2" x 2", be of passport quality and bear on the back the date on which the photographs were taken, the signature of the applicant and that of the Commissioner of Oaths or that of an officer, director, partner orbranch manager of the sponsoring firm.
7. EDUCATION
A. INSTRUCTION: DATE OBTAINED
NAME OF LAST SCHOOL ATTENDED IN EACH LEVEL DEGREE OR DIPLOMA Y M D
________________________________________________________________________
High School or Secondary Level
________________________________________________________________________
Post-Secondary, College, CEGEP or University
________________________________________________________________________
Professional Education
________________________________________________________________________
Other
________________________________________________________________________
| DATE COMPLETED | ||||
| Have you successfully completed: | YES | NO | EXEMPT* | Y M D |
Branch Managers' Examination (IFIC) | o | o | o | ___ ___ ___ |
| Branch Managers Qualifying Exam (CSI) | o | o | o | ___ ___ ___ |
| Canadian Commodity Supervisors Exam (CSI) | o | o | o | ___ ___ ___ |
| Canadian Futures Exam Program (CSI), Part I | o | o | o | ___ ___ ___ |
| Canadian Futures Exam Program (CSI), Part II | o | o | o | ___ ___ ___ |
| Canadian Investment Funds Course (IFIC) | o | o | o | ___ ___ ___ |
| Canadian Investment Management Course (CSI), Part II | o | o | o | ___ ___ ___ |
| Canadian Options Course (CSI) | o | o | o | ___ ___ ___ |
| Canadian Securities Course (CSI) | o | o | o | ___ ___ ___ |
| Chartered Financial AnalystsCourse (AIMR), First Year | o | o | o | ___ ___ ___ |
| Chartered Financial Analysts Course (AIMR), Complete | o | o | o | ___ ___ ___ |
Conduct and Practices Handbook Exam (CSI) | o | o | o | ___ ___ ___ |
| Effective Management in the Securities Industry Course (CSI) | o | o | o | ___ ___ ___ |
| Investment Funds in Canada Course (ICB) | o | o | o | ___ ___ ___ |
| National Commodities Futures Examination (CSI) | o | o | o | ___ ___ ___ |
New Entrants' Examination (CSI) | o | o | o | ___ ___ ___ |
| Officers', Partners' or Directors' Examination (IFIC) | o | o | o | ___ ___ ___ |
| Partners, Directors and Senior Officers Qualifying Exam (CSI) | o | o | o | ___ ___ ___ |
Professional Financial Planning Course (CSI) | o | o | o | ___ ___ ___ |
| Real Estate Securities Course (UBC) | o | o | o | ___ ___ ___ |
| Registered Options Principals Exam Program (CSI) | o | o | o | ___ ___ ___ |
| Other (Specify) ___________________________________ | o | o | o | ___ ___ ___ |
________________________________________________________________________
* If you have been granted exemption, attach full particulars.
B. Have you ever applied for and been refused exemptions from any of the above listed examination requirements?
(If so, give particulars as an attachment).
o YES o NO
________________________________________________________________________
8. EMPLOYMENT HISTORY
A. The following information constitutes full disclosure of your business activities, including any periods of self-employment and unemployment, for 10 years immediately prior to the date of this application, excluding any summer employment while a full-time student, but including all securities or commodities industry employment during and prior to the ten-year period.
NAME AND NAME AND TITLE NATURE OF REASONS FOR
ADDRESS OF OF IMMEDIATE EMPLOYMENT LEAVING FROM TO
EMPLOYER SUPERIOR AND DUTIES Y M Y M
OF APPLICANT
________________________________________________________________________
PRESENT
________________________________________________________________________
PREVIOUS
________________________________________________________________________
B. Have you ever been discharged by an employer for cause? Check x as applicable.
(If yes, give particulars as an attachment).
o YES o NO
________________________________________________________________________
9. RESIDENTIAL HISTORY - give all home addresses for the past 10 years. Include street, city, province.
________________________________________________________________________
PRESENT POSTAL CODE FROM TO
Y M Y M
________________________________________________________________________
PREVIOUS
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I 0. REFERENCES
Give three names as references, excluding relatives and persons associated with the sponsoring firm. References must include a bank or trust company at which you have an account (give account number).
________________________________________________________________________
NAME FIRM NAME BUSINESS ADDRESS - include postal code OCCUPATION
TELEPHONE - include area code
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Account No. at reference bank or trust company
________________________________________________________________________
NOTE: Account No. need not be given if this form is accompanied by a written reference from a bank or trust company with which the applicant has an account.
________________________________________________________________________
ANSWER "YES" OR "NO" TO EACH OF QUESTIONS 1 1 TO 20 INCLUSIVE. Please x
IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS "YES", YESORNO
COMPLETE DETAILS MUST BE ATTACHED BY WAY OF EXHIBIT
11.CHANGE OF NAME
INSTRUCTION: Name changes resulting from marriage, divorce,
court order or any other process must be listed here giving appropriate dates.
Have you ever had, used, operated under, or carried on business under any o o
name other than the name mentioned in Question 1 of this form, or have you ever
been known under any other name?
Previous Name _________________________________ Date ________________
12. PRIOR REGISTRATION OR LICENSING
A. Are you now or have you ever been registered or licensed, or applied for o o
registration or a licence in any capacity under any act or regulation thereof,
regulating trading in securities or exchange contracts (commodities or
commodity futures contracts) of any province, territory, state or country?
List all authorities with whom you were registered and the dates of registration.
State whether the registration is currently in effect.
Authority _________________________________ Date ________________
Authority _________________________________ Date ________________
B. Are you now, or have you ever been a partner, shareholder, director or o o
officer of any company or of a partnership which has been registered or
licensed, or is now registered or licensed (except as an issuer if you are or
have been solely a shareholder) in any capacity under any act or regulation
thereof, regulating trading in securities or exchange contracts (commodities
or commodity futures contracts) of any province, territory, state or country?
C. Are you now or have you ever been registered or licensed, or applied for o o
registration or a licence, under any legislation which requires registration
or licensing to deal with the public in any capacity other than
trading in securities or exchange contracts (commodities
or commodity futures contracts) in any province, territory, state or country?
QUESTIONS 13 TO 18 INSTRUCTION: In answering Question
13 to 18, and particularly Question 15, you may need assistance from
an authorized officer of the sponsoring firm or from a legal adviser. Full
details are required as attachments in respect of any question to which
the applicant answers "yes". These details must include the circumstances,
the relevant dates, the names of the parties involved and the final
determination if known.
13. REFUSAL, SUSPENSION, CANCELLATION OR DISCIPLINARY MEASURE
A. Have you everbeen refused registration or a licence, or has your o o
registration or licence been suspended or cancelled, under any act or
regulation thereof, regulating trading in securities or exchange contracts
(commodities or commodity futures contracts) of any province, territory,
state or country?
B. Are you now or have you ever been a partner, shareholder, director or o o
officer of a company or of a partnership which has, during the time of your
association with it, been refused registration (except a registration as an
issuer if you are or have been solely a shareholder) or a licence, or whose
registration has been suspended or cancelled under the act, or regulation
thereof, regulating trading in securities or exchange contracts (commodities
or commodity futures contracts) of any province, territory, state or country?
C. Have you everbeen refused registration or a licence, or has your o o
registration or licence been suspended or cancelled, under any legislation
which requires registration or licensing to deal with the public in any capacity
other than trading In securities or exchange contracts (commodities
or commodity futures contracts) in any province, territory, state or country?
D. Have you been denied the benefit of any exemption from registration or o o
licensing provided by any act or regulation thereof regulating trading in
securities or exchange contracts (commodities or any commodity futures
contracts) of any province, territory, state or country?
E. Has any prior or current registration or licensing to deal or trade in securities o o
or exchange contracts (commodities or commodity futures contracts) held
by you or any partnership or company of which you were at the time of such
event a partner, officer or director or holder of voting securities carrying more
than 5 percent of the votes carried by all outstanding voting securities ever
been the subject of disciplinary action undertaken by any authority regulating
or supervising trading in securities or exchange contracts (commodities or
commodity futures contracts)?
14. SELF-REGULATORY ORGANIZATIONS
Have you or has any partnership or company of which you are or were at the time
of such event a partner, director, officer or holder of voting securities carrying more
than 5% of the votes carried by all outstanding voting securities:
A. Ever been a member of any stock exchange or exchange contracts o o
exchange (commodities exchange or commodity futures exchange)
association of investment dealers, investment bankers, brokers,
broker-dealers, mutual fund dealers, exchange contracts dealer
(commodity futures dealers), investment counsel, other professional
association or any similar organization in any province, territory, state
or country?
B. Ever been refused registration or licensing or approval for membership o o
or approval in any other capacity by/in any of the institutions or
associations described in Question 14A?
C. Ever been the subject of disciplinary action undertaken by any authority o o
as described in question 14A?
15. OFFENCES UNDER THE LAW
INSTRUCTION: Offences under such federal statutes as the Income Tax
Act (Canada) and the Immigration Act (Canada) constitute criminal offences
and must be disclosed when answering this question. Where you have pleaded guilty
or been found guilty of an offence, such offence must be reported even though an
absolute or conditional discharge has been granted.
It should be noted that pleas or findings of guilt for impaired driving are Criminal
Code (Canada) matters and must be disclosed.
You are not required to disclose any offence for which a pardon has been granted
under the Criminal Records Act (Canada)and such pardon has not been
revoked. Under such circumstances, the appropriate response would be "No".
If you are in doubt as to previous dealings you have had with law enforcement
agencies and the applicability of this question with respect to such encounters,
you should obtain the advice of an authorized officer of your sponsor or a legal
adviser.
A. Past Offences Involving Securities, Commodities, Insurance or Real Estate o o
Have you ever pleaded guilty or been found guilty under any law of any
province, territory, state or country of any offence relating to trading in
securities, exchange contracts (commodities or commodity futures
contracts), insurance or real estate or with the theft thereof, or with
any related offence, or been a party to any proceedings taken on
account of fraud arising out of any trade in or advice in respect thereof?
B. Past Offences Involving Other Criminal Offences or Contraventions o o
Have you ever pleaded guilty or been found guilty under any law of
any province, territory, state or country for contraventions or other
criminal offences not noted in A above?
C. Current Charges or Indictments o o
Are you currently the subject of a charge or Indictment,
under any law of any province, territory, state or country for
contraventions, criminal offences or other conduct of the type
described in A or B above?
D. Partnership or Company Offences or Current Charges or Indictments o o
Has any partnership or company of which you are or were at the time
of such event a partner, officer, director or a holder of voting securities
carrying more than 5% of the votes carried by all outstanding voting
securities, ever pleaded guilty or been found guilty, or is any such
partnership or company currently the subject of a charge or indictment,
under any law of any province, territory, state or country for contraventions,
criminal offences or other conduct of the type described in A or B above?
16. CIVIL PROCEEDINGS
Has any claim been made successfully or, to your knowledge, is any claim pending
in any civil proceedings before a court or other tribunal in any province, territory,
state or country which was, or is, based in whole or in part on fraud, theft, deceit,
misrepresentation or similar conduct?
A. Against you? o o
B. Against any partnership or company of which you are or were at the time o o
of such event, or at the time such proceedings were commenced, a
partner, director, officer or holder of voting securities carrying more
than 5% of the votes carried by all outstanding voting securities?
17. BANKRUPTCY
A. Under the law of any province, territory, state or country have you ever:
a) been declared bankrupt or made a voluntary assignment in o o
bankruptcy?
b) made a proposal under any legislation relating to bankruptcy o o
or insolvency?
c) been subject to or instituted any proceedings, arrangement or o o
compromise with creditors including, without limitation, produced
a declaration under the Quebec Voluntary Peposit of Salary
Wages Law or had a receiver and/or manager appointed to
hold your assets?
If yes, and if applicable, attach copy of any discharge, release or document
with similar effect.
B. Has any partnership or corporation of which you are or were at the time of
such event a partner, director, officer or holder of voting securities carrying
more than 5% of the votes carried by all outstanding voting securities ever.
a) been declared bankrupt or made a voluntary assignment in o o
bankruptcy?
b) made a proposal under any legislation relating to bankruptcy o o
or insolvency?
c) been subject to proceedings under any legislation relating to o o
the winding up, dissolution or companies' creditors arrangements?
d) been subject to or instituted any proceedings, arrangement or o o
compromise with creditors or had a receiver and/or manager
appointed to hold its assets?
If yes, and if applicable, attach copy of any discharge, release or document
with similar effect.
18. JUDGEMENT OR GARNISHMENT
Has any judgement or garnishment ever been rendered against you or is any o o
judgement or garnishment outstanding against you, in any civil court in any province,
state or country for damages or other relief in respect of a fraud or for any reason
whatsoever?
19.SURETY BOND OR FIDELITY BOND
A. Have you ever applied for a surety bond or fidelity bond and been refused? o o
If yes, attach name and address of bonding company, and when and why
the bond was refused.
B. Are you presently bonded? o o
20. BUSINESS ACTIVITIES
A. Will you be actively engaged in the business of the firm with which you are o o
now applying and devote the major portion of your time thereto?
B. Are you engaged in any other business or have any other employment for o o
gain except your occupation with the firm with which you are now applying?
If so, attach full details including the full name and address of the o o
business, the nature of the business, your title or position and the amount
of time you devote to the business.
C. Are you a partner, director, officer, shareholder or other contributor of o o
capital of a partnership or of a company having as its principal business
that of a broker, dealer or adviser in securities or exchange contracts
(commodities or commodity futures contracts) other than the firm with
which you are now applying? If so, attach full details.
21. A. State the number, value, class and percentage of shares or the
amount of partnership interest you own or propose to acquire upon
approval. If acquiring shares upon approval, state source (e.g.,
treasury shares, or if upon transfer, state name of transferor).
B. State the value of subordinated debentures or bonds of the firm to be held
by you or any other subordinated loan to be made by you to the firm.
C. Are you or will you upon approval be the beneficial owner of the shares,
bonds, debentures, partnership interest or other notes held by you?
If NOT, state name, residential address and occupation of the beneficial
owner.
________________________________________________________________________
CAUTION
FILING OF ANY FALSE INFORMATION OR FAILURE TO DISCLOSE FULL INFORMATION REQUIRED BY OR ON THIS APPLICATION MAY RESULT IN ITS REJECTION OR IN DISCIPLINARY ACTION TAKEN AGAINST THE APPLICANT AND/OR THE SPONSORING FIRM WITHIN THE PROVISIONS OF THE APPLICABLE SECURITIES AND/OR COMMODITY FUTURES LEGISLATION, REGULATIONS, RULES AND POLICY STATEMENTS OF THE SECURITIES REGULATORY AUTHORITIES AND WITHIN THE TERMS OF THE BY-LAWS, RULINGS, RULES AND/OR REGULATIONS OF ANYONE OF THE SELF REGULATORY ORGANIZATIONS TO WHICH THIS APPLICATION IS SUBMITTED, OR MAY RESULT IN A REFUSAL TO REGISTER THE APPLICANT.
CERTIFICATE AND AGREEMENT OF APPLICANT AND SPONSORING FIRM
The undersigned hereby certify that the forgoing statements are true and correct to the best of our knowledge, information and belief.
We understand that we are obligated to notify the Securities Commissions or similar authorities marked in Question 4 in writing of any material change therein as prescribed by the applicable securities and/or commodity futures legislation and we hereby undertake to notify any self-regulatory organization marked in Question 4 in writing of any material change therein as prescribed by any by-law or rule of the respective self-regulatory organization.
We agree that we are conversant with the securities and/or commodity futures legislation, regulations, rules and policy statements of the Securities Commissions or similar authorities marked in Question 4 and that we are conversant with the by-laws, rulings, rules and regulations of the self-regulatory organizations marked in Question 4.
We understand that we are obligated to observe and comply with the securities and/or commodity futures legislation, regulations, rules and policy statements of the Securities Commissions or similar authorities marked in Question 4 as they are from time to time amended or supplemented, and we agree to keep ourselves fully informed about them as so amended and supplemented. We understand that any approval granted pursuant to this application may be revoked, terminated or suspended at any time in accordance with the then-applicable securities and/or commodity futures legislation, regulations, rules and policy statements.
We agree, if the undersigned sponsoring firm is a member of the self-regulatory organizations marked in Question 4, to be bound by and to observe and comply with the by-laws, rulings, rules and regulations of the self-regulatory organizations as they are from time to time amended or supplemented, and we agree to keep ourselves fully informed about them as so amended and supplemented. We submit to the jurisdiction of the self-regulatory organizations marked in Question 4 and, wherever applicable, the Governors, Directors and the committees thereof, and we agree that any approval granted pursuant to this application may be revoked, terminated or suspended at any time in accordance with the then-applicable by-laws, rulings, rules and regulations. In the event of any revocation or termination, the undersigned applicant agrees forthwith to terminate the applicant's associations with the undersigned sponsoring firm and thereafter not to accept employment with or perform services of any kind for any member or member house of the self-regulatory organizations marked in Question 4 or any approved affiliated company or other affiliate of such member or member house, in each case if and to the extent provided in the then applicable by-laws, rulings, rules and regulations of the self-regulatory organizations. Our obligations above are joint and several.
We agree to the transfer of this application form, without amendment, to any of the self-regulatory organizations listed in Question 4 of this application form in the event that some time in the future the undersigned applicant applies to such self-regulatory organization.
The undersigned applicant has discussed the questions in this application and in particular Question 15 and 16 with a compliance officer or branch manager of this firm. The undersigned authorized officer is satisfied that the applicant fully understands the questions, and further certifies on behalf of the sponsoring firm that the applicant will be engaged as registered or approved.
The undersigned applicant acknowledges and consents that any of the self-regulatory. organizations or Securities Commissions or similar authorities marked in Question 4 may obtain any information whatsoever from any source, as permitted by law in any jurisdiction in Canada or elsewhere.
Dated at ________________________ this _________ day of ___________________________ _________
(Day) (Month) (Year)
_________________________________________ _________________________________________
(Signature of applicant) (Name of sponsoring Firm)
BY_______________________________________
(Partner or AuthorizedOfficer)
AFFIDAVIT in the matter of the Securities Act
I, _______________________________, _________________________________, of ________________________
(Name in Full) (Occupation) (Address)
of the _________________ of ____________________ in the _______________ of____________________, MAKE
(City, etc.) (Province, etc.)
OATH (OR SOLEMNLY AFFIRM) AND SAY THAT:
1. I have read and understand the questions and the "Caution" in this application.
2. The answers I have given to the questions in this application and any attachments to it are true.
3. I consent to the information in my application for registration or for approval or renewal or reinstatement of registration being used to conduct a suitability investigation, including a criminal records check, regarding my application.
4. I understand that failure by me to disclose information accurately about my criminal history, if any, may constitute an offence under the provincial or territorial Securities Act or equivalent, or under the Criminal Code (Canada).
SWORN (OR AFFIRMED) BEFORE ME in
the ______________________ of ______________________________ ) ___________________________________
(City, etc.) ) (Signature of Deponent)
)
in the______________________ of _____________________________ )
(Province, etc.) )
) ___________________________________
on this ______________ day of _____________________ , __________ ) (Signature of Commissioner, of Oaths, Notary Public orother official authorized by law to administer oaths)
(Month) (Year) )
It is an offence under the Securities Act to file an application containing a statement that, at the time
and in light ofthe circumstances in which it is made, is a misrepresentation.