33-109F1 - Notice of Termination [F - Rescinded]

Enter the following information using the online version of this submission at the NRD web site (www.nrd.ca). If the NRD filer is relying on the temporary hardship exemption in NI 31-102 this form is required to be delivered to the regulator in paper format.

1. Individual

Name of individual:   _______________________          

NRD number of individual:    _________________

2. Business location

Address of business location:   _____________________     

NRD number of business location:  __________________    

3. Termination

Effective date of termination:   ________________________   

Indicate whether the individual: 

•  was dismissed for cause ______________________
  
•  was dismissed in good standing ______________________
  
•  resigned in good standing ______________________
  
•  is deceased ______________________

Include details regarding any:

• unresolved client complaints:   
  
• internal discipline matters:
  
• restrictions for violation of regulatory requirements:
  
• financial obligations the individual has to clients:
   

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 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 and Labrador, Northwest Territories, Yukon Territory and Nunavut.

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 provided in Schedule "A".

 
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

The following certification is to be used when submitting this form in NRD format:

I am making this submission as agent for the NRD filer.  By checking this box I certify that all statements of fact in this submission were provided to me by the NRD filer.

The following certification is to be used when submitting this form in paper format:

I, the undersigned, certify that I have read and that I understand the questions in the notice and the Warning set out above.  I also certify that all statements of fact made in the answers to the questions are true