Form 5 - Uniform application for renewal of licence or registration [F - Rescinded]
| Published Date: | 1996-07-05 |
|---|---|
| Effective Date: | 1996-09-01 |
| Rescinded Date: | 2001-03-28 |
DO NOT PRINT & SUBMIT THIS FORM. CONTACT THE COMMISSION FOR AN OFFICIAL COPY.
FORM 5
Uniform Application for Renewal
of Licence or Registration
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FOR OFFICE USE ONLY
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FILE NUMBER REGISTRATION NO.
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APPROVED BY DATE OF APPROVAL
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KEYED BY DATE KEYED
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RESTRICTION
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PLEASE READ INSTRUCTIONS CAREFULLY.
APPLICANT TO COMPLETE ALL SHADED AREAS. CHECK (*) APPROPRIATE BOXES SHOWN.
IF INFORMATION HAS CHANGED, ATTACH AN EXHIBIT GIVING DETAILS.
| AS NOTED | CHANGED | |
| APPLICANT NAME | (1) [] | [] |
| EMPLOYER NAME | (2) [] | [] |
| BUSINESS ADDRESS | (3) [] | [] |
| REGISTRATION OF THE ABOVE IS DUE FOR RENEWAL ON | ||
| UNDER ACT, AS (4) | (4) [] | [] |
| REGISTRATION FEE OTHER FEE TOTAL FEE REQUIRED | ||
| APPLICANT LEGAL NAME (5) | (5) [] | [] |
| BUSINESS TELEPHONE(6(a)) (6(b)) FAX NO. ( ) | (6) [] | [] |
| SERVICE ADDRESS IN B.C. (7) | (7) [] | [] |
EMPLOYER FILE NUMBER
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RESIDENCE ADDRESS
AND POSTAL CODE
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[] (/) I REQUEST RENEWAL OF THE ABOVE }
REGISTRATION } SEE REVERSE FOR INSTRUCTIONS
[] (/) I DO NOT DESIRE RENEWAL OF THE }
ABOVE REGISTRATION }
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AMENDMENTS TO INFORMATION -- INDIVIDUAL APPLICANT
Bankruptcy, judgments, criminal or civil proceedings, since the date of last application or renewal.
INSTRUCTIONS: 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. It should be noted that pleas or findings of guilt for impaired driving are Criminal Code (Canada) matters and must be disclosed. 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.
You are not required to disclose any offences 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."
| YES | NO | ||
| A) | Have you pleased guilty or been found guilty under any law of any province, state or country, excepting minor traffic violations? | [] | [] |
| B) | Are your presently subject to a charge or indictment? | [] | [] |
| C) | Have you personally, or has any business of which you are or were an officer, director or partner, ever been subject to bankruptcy proceedings? | [] | [] |
| D) | Are there any pending legal proceedings against you or against any business of which you are an officer, director or partner? | [] | [] |
| E) | Has any judgment, which is unsatisfied, ever been rendered against you personally or against any business of which you were at the time an officer, director or partner, in any civil court in British Columbia, or else where, for any reason whatsoever? | [] | [] |
| F) | Have you changed any other registration information from that previously submitted? | [] | [] |
AMENDMENTS TO INFORMATION -- CORPORATE, PARTNERSHIP APPLICANT
| Since the date of the last application, has the applicant: | YES | NO | |
| A) | Been subject to proceedings in bankruptcy? | [] | [] |
| B) | Had a judgement of a court rendered against them in any civil court in British Columbia or elsewhere, for any reason whatsoever, which is unsatisfied? | [] | [] |
| C) | Been subject to any legal proceedings which are now pending? | [] | [] |
| D) | Had any changes in officers, directors or partners? | [] | [] |
| E) | Changed any other registration information from that previously submitted? | [] | [] |
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, ATTACH AN EXHIBIT GIVING DETAILS
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APPLICANT'S SIGNATURE DATE
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CERTIFICATE OF APPROVAL BY INTENDED EMPLOYER PRINT NAME DATE
(SIGNATURE OF EMPLOYER)
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SIGNING AUTHORITY (SEE REVERSE FOR INSTRUCTIONS) PRINT NAME DATE
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THIS FORM MUST BE COMPLETED AND RETURNED TO THE ABOVE ADDRESS WITH REQUIRED FEE, 30 DAYS PRIOR TO DUE DATE. RETURN TOP COPY ONLY. RETAIN BOTTOM COPY FOR YOUR RECORDS.
WARNING
ANY APPLICATION CONTAINING A FALSE STATEMENT MAY RESULT IN REFUSAL, SUSPENSION OR CANCELLATION OF ANY REGISTRATION
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Freedom of Information and Protection of Privacy Act
The personal information requested on this form, when collected by the British Columbia Securities Commission (BCSC), is collected under the authority of and used for the purpose of administering the Securities Act. Questions about the collection or use of the information collected on this form by the BCSC can be directed to the Registration Supervisor (604-899-6692), 200 - 865 Hornby Street, Vancouver, British Columbia V6Z 2H4.
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SUBMIT THIS COPY
IF RENEWAL REQUESTED
Check (/) appropriate box, complete all shaded areas, sign and return this form with required fee to the Issuing Office 30 days prior to due date. This form must also be completed by intended employer if applicable. (See below CERTIFICATE OF APPROVAL BY INTENDED EMPLOYER.)
IF RENEWAL NOT REQUIRED
Check (/) appropriate box, sign and return this form to the return address. Upon termination of registration of:
An adviser, a broker, a dealer or investment dealer under the Securities Act is required to submit the following:
1. Termination letter giving date of cessation of business.
2. Written auditor's confirmation to the effect that all financial obligations under the applicable Act have been discharged and that all trust funds/client accounts have been properly disbursed.
CERTIFICATE OF APPROVAL BY INTENDED EMPLOYER to be completed as follows:
Securities Act
All salesman categories must be endorsed by employer noted in item (2) on the front of this form.
Note: All exhibits must be duly initialled.