Form 3 - Application for registration as dealer, adviser or underwriter [F - Rescinded]
| Published Date: | 1997-01-31 |
|---|---|
| Rescinded Date: | 1997-01-31 |
(Published and Effective dates are unknown)
FORM 3
Application for Registration as
Dealer, Adviser or Underwriter
Check one: Securities Act _____ Commodity Contract Act _____
Note: Should any space be insufficient for your answers, a statement may be attached and marked as an exhibit cross-referencing each statement to the item to which it pertains providing it is initialled by the applicant and the Commissioner taking the affidavit.
Application is made for registration under the ____________________________________________ Act.
in the category of _______________________________________________________________________
1. (a) Name of Applicant _________________________________________________________
(b) Head Office Business Address _______________________________________________
Telephone No. ______________________ Postal Code ______________________
(c) Address for service in British Columbia ________________________________________
Telephone No. ______________________ Postal Code ______________________
2. The applicant maintains accounts at the following bank(s): (State bank and branches through which business is transacted)
___________________________________________________________________
_______________________________ Fiscal Year End: _______________________
3. Is applicant applying for registration of any branch offices? If so, state addresses:
____________________________________________________________________
INSTRUCTION: Answer "Yes" or "No" to the following questions. If "Yes" give particulars.
4. Has the applicant, or to the best of the applicant's information and belief has any affiliate of the applicant,
(a) been registered in any capacity under the Securities Act/Commodity Contract Act of British Columbia?
____________________________________________________________________
(b) applied for registration, in any capacity, under the Securities Act/Commodity Contract Act of British Columbia?
____________________________________________________________________
5. Is the applicant, or to the best of the applicant's information and belief is any affiliate of the applicant, now, or has any such person or company been,
(a) registered or licensed in any capacity in any other province, state or country which requires registration or licensing to deal or trade in securities?
____________________________________________________________________
(b) registered or licensed in any other capacity in British Columbia or any other province, state or country under any legislation which requires registration or licensing to deal with the public in any capacity? (e.g. as an insurance agent, real estate agent, private investigator, mortgage broker, etc.)
____________________________________________________________________
(c) refused registration or a licence mentioned in 5(a) or (b) above or has any registration or licence been suspended or cancelled in any category mentioned in 5(a) or (b) above?
____________________________________________________________________
(d) denied the benefit of any exemption from registration provided by the Securities Act/Commodity Contract Act of British Columbia, or similar exemption provided by securities acts or regulations of any other province, state or country?
____________________________________________________________________
6. Is the applicant, or to the best of the applicant's information and belief is any affiliate of the applicant, now, or has any such person or company been,
(a) a member of any Stock Exchange, Investment Dealers Association, Investment Bankers, or similar organization, in any province, state or country?
____________________________________________________________________
(b) refused membership in any Stock Exchange, Investment Dealers Association, Investment Bankers, or similar organization, in any province, state or country?
____________________________________________________________________
(c) suspended as member of any Stock Exchange, Investment Dealers Association, Investment Bankers, or similar organization, in any province, state or country?
____________________________________________________________________
7. Has the applicant, or to the best of the applicant's information and belief has any affiliate of the applicant, operated under, or carried on business under, any name other than the name shown in this application?
____________________________________________________________________
8. Has the applicant, or to the best of the applicant's information and belief, has any affiliate of the applicant,
(a) ever been convicted under the law of any province, state or country, excepting minor traffic violations?
____________________________________________________________________
Is there currently an outstanding charge or indictment against the applicant or affiliate?
____________________________________________________________________
INSTRUCTION: Question 8(a) refers to all laws, e.g. Criminal, Immigration, Customs, Liquor, etc. of any province, state or country, in any part of the world. You are not required to disclose any convictions for which a pardon has been granted under the Criminal Records Act (Canada), and which pardon has not been revoked.
(b) ever been the defendant or respondent in any proceedings in any civil court in any jurisdiction in any part of the world wherein fraud was alleged?
____________________________________________________________________
(c) at any time declared bankruptcy, or made a voluntary assignment in bankruptcy? (If "Yes", give particulars and also attach a certified copy of discharge)
____________________________________________________________________
(d) ever been refused a fidelity / surety bond?
____________________________________________________________________
9. Set out in the space provided, the name of the applicant, or the name of and position held by each director, officer or partner of the applicant seeking or holding registration.
NOTE: an underwriter may not trade with the public.
__________________________________________________________________________
Names of persons who will act Names of persons who will act
(In addition to last name, give (In addition to last name, give
full first and middle names) Office Held full first and middle names) Office Held
__________________________________________________________________________
1. 5.
2. 6.
3. 7.
4. 8.
__________________________________________________________________________
10. Attach and mark as an exhibit:
(a) a completed Form 4 for each director, officer or partner of the applicant seeking or holding registration.
(b) for each person or company who is a director, officer or partner of the applicant and not referred to in clause (a), the information required by Form 4.
(c) In the case of applicants for registration as investment counsel only, a letter from each person who, on behalf of the applicant will give investment advice, outlining directly related experience of such person so as to justify designation by the Director of such person to so act.
11. A - Capitalization of a Company:
Other than a Security Issuer, complete below or attach marked as an exhibit to the application a statement containing the information called for below, to provide information with respect to the financial structure and control of the applicant company.
(a) The authorized and issued capital of the company, stating:
Preferred Shares: Number __________ $ Value __________
Common Shares: Number __________ $ Value __________
(1) authorized capital
____________________________________________________________________
(2) issued
____________________________________________________________________
(3) total dollar value of other securities:
(i) Bonds
____________________________________________________________________
(ii) Debentures
____________________________________________________________________
(iii) Any other loans, state source and maturity dates
____________________________________________________________________
TOTAL $ __________________
(b) The names, addresses and usual place of residence of registered, and direct, and indirect, beneficial owners of each class of security or obligation issued, and, if a trust is the beneficial owner, the names, addresses and usual place of residence of each person or company having a beneficial interest in the trust, and the nature and extent of the holdings and percentage of interest attributable to each security holder, lender or cestui que trust (beneficiary).
(c) State name and address of every depository holding any of the assets of the company:
INSTRUCTIONS:Answer "Yes" or "No" to the following questions. If "Yes" give particulars.
(d) Has any person or company undertaken to act as a guarantor in relation to the financial or other undertakings of the applicant?
____________________________________________________________________
(e) Has a Subordination Agreement been executed by the creditor(s) in relation to loans owing by the applicant?
____________________________________________________________________
(f) Is there any person or company whose name is not disclosed in the statement called for by (b) above who has any direct or indirect interest in the applicant, either beneficially or otherwise?
____________________________________________________________________
B - Capitalization of a Partnership or Proprietorship:
Attach, marked as an exhibit to the application, a statement containing the information called for below with respect to the assets of the partnership or proprietorship, and demonstrate therein the degree of control (voting power) of each of the participants in the applicant.
(a) Amount of paid-in capital
$ ___________________________________________________________________
(b) Description of the assets:
_____________________________________________________________________
(c) State name and address of every depository holding any of the assets:
_____________________________________________________________________
(d) Source, amount and maturity date of any obligations owing by the partnership, if any: (Where applicable, give names and addresses of creditors).
_____________________________________________________________________
INSTRUCTION: Answer "Yes" or "No" to the following questions. If "Yes" give particulars.
(e) Has any person or company undertaken to act as a guarantor in relation to the financial or other undertakings of applicant?
_____________________________________________________________________
(f) Has a Subordination Agreement been executed by the creditor(s) in relation to loans owing by the applicant?
_____________________________________________________________________
(g) Is there any person or company whose name is not disclosed above who has any interest in the applicant, either beneficially or otherwise?
_____________________________________________________________________
_____________________________________________________________________
DATED at __________________________
_______________________________________
(Name of Applicant)
this ___________ day of _________ 19___
By _____________________________________
(Signature of applicant, director, officer or partner)
_______________________________________
(Official capacity)
___________________________________________________________________________
AFFIDAVIT
In the matter of the Securities Act/Commodity Contract Act
Province of British Columbia ) I, _____________________________________
) (Name in full)
)
__________ of ____________ ) of the __________________________________
)
To-Wit: ) in the Province of _________________________
MAKE OATH AND SAY:
1. I am the applicant (or a director, officer or partner of the applicant) herein for registration and I signed the application.
2. The statements of fact made in the application are true.
SWORN before me at the ____________________ )
)
in the ____________ of ______________________ ) ___________________________________
) (Signature of Deponent)
this ____________ day of _____________ 19 ____ )
)
_________________________________________ )
(A Commissioner, etc.)
It is an offence under the Securities Act/Commodity Contract Act to file an applicationcontaining a statement that, at the time and in light of the circumstances in which it ismade, is a misrepresentation.