Form 3 - Application for registration as dealer, adviser or underwriter [F - Rescinded]
| Published Date: | 1997-01-03 |
|---|---|
| Effective Date: | 1997-01-31 |
| Rescinded Date: | 2001-03-28 |
FORM 3
Application for Registration as
Dealer, Adviser or Underwriter
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.
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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.
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Application is made for registrationunder the Securities Act. In the category of
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- (a) NAME OF APPLICANT
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(b) HEAD OFFICE BUSINESS ADDRESS POSTAL CODE
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TELEPHONE NO. FAX NO. E-MAIL (INTERNET)
area code area code
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(c) ADDRESS OF REGISTERED OFFICE IN BRITISH COLUMBIA POSTAL CODE
_________________________________________________________________
TELEPHONE NO. FAX NO. E-MAIL (INTERNET)
area code area code
_________________________________________________________________ - The applicant maintains accounts at the following bank(s): (state bank and branches through which business is transacted).
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_________________________________________________________________ - Is applicant applying for registration of any branch offices? Check (x) as applicable. If so, state address(es).
o YES o NO POSTAL CODE
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POSTAL CODE
___________________________________________________________________ - Fiscal Year End
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INSTRUCTION: Answer "Yes" or "No" to the following questions. If "Yes" give particulars.
Please (x)
YES NO - 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
(or former Commodity Contract Act) of British Columbia? o o
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(b) applied for registration, in any capacity, under the Securities Act
(or former Commodity Contract Act) of British Columbia? o o
___________________________________________________________________ - 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 or exchange contracts? o o
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(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.) o o
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(c) refused registration or a licence mentioned in 6 (a) or (b) above or
has any registration or licence been suspended or cancelled in any
category mentioned in 6 (a) or (b) above? o o
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(d) denied the benefit of any exemption from registration provided by
the Securities Act (or former Commodity Contract Act)
of British Columbia, or similar exemption provided by securities
acts or regulations of any other province, state or country? o o
____________________________________________________________________ - 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? o o
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(b) refused membership in any Stock Exchange, Investment Dealers
Association, Investment Bankers, or similar organization, in any
province, state or country? o o
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(c) suspended as member of any Stock Exchange, Investment Dealers
Association, Investment Bankers, or similar organization, in any
province, state or country? o o
_____________________________________________________________________ - 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? o o
_____________________________________________________________________ - Is there currently an outstanding charge or indictment against the applicant
or, to the best of the applicant's information and belief, an affiliate or
associate of the applicant? o o
_____________________________________________________________________ - Has the applicant, or to the best of the applicant's information and belief,
any affiliate or associate of the applicant,
(a) ever been convicted of an offence under the law? o o
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(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,
theft, deceipt, misrepresentation or similar conduct was alleged? o o
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(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) o o
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(d) at any time had a receiver or receiver manager appointed to hold
its assets? o o
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(e) ever been refused a fidelity / surety bond? o o
______________________________________________________________________ - 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.
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NAMES OF PERSONS WHO WILL ACT
(IN ADDITION TO LAST NAME, GIVE FULL OFFICE HELD
FIRST AND MIDDLE NAMES)
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1
_____________________________________________________________________
2
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3
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4
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5
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6
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7
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8
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_____________________________________________________________________ - 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.
_____________________________________________________________________ - Answer A or B as appropriate.
A - Capitalizationofa 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:
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PREFERRED SHARES NUMBER VALUE COMMON SHARES NUMBER VALUE
$ $
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(1) AUTHORIZED CAPITAL (2) ISSUED
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(3) TOTAL DOLLAR VALUE OF OTHER SECURITIES
(I) BONDS (II) DEBENTURES
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(III) ANY OTHER LOAN(S) - state source MATURITY DATE(S) TOTAL
Y M D
__ __ __ $
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(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:
INSTRUCTION: Answer "Yes" or "No" to the following questions. If "Yes" give particulars.
Please (x)
YES NO
(d) Has any person or company undertaken to act as a guarantor
in relation to the financial or other undertakings of the applicant? o o
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(e) Has a Subordination Agreement been executed by the creditor(s)
in relation to loans owing by the applicant? o o
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(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? o o
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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.
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(a) Amount of paid-in capital (b) Description of the assets
$
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(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).
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INSTRUCTION: Answer "Yes" or "No" to the following questions. If "Yes" give particulars.
Please (x)
YES NO
(e) Has any person or company undertaken to act as a guarantor in
relation to the financial or other undertakings of applicant? o o
_____________________________________________________________________
(f) Has a Subordination Agreement been executed by the creditor(s)
in relation to loans owing by the applicant? o o
_____________________________________________________________________
(g) Is there any person or company whose name is not disclosed above
who has any interest in the applicant, either beneficially or otherwise? o o
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DATED at ______________________ | __________________________ |
(Name of Applicant) |
this ______ | day of _________________ | _______ | By ______________________________ |
(Day) | (Month) | (Year) | ( Signature of applicant, director, officer or partner) |
_________________________________ | |
(Official Capacity) |
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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 am the applicant (or partner, director, or officer of the applicant) for registration and I signed the application.
2. The statements of fact made in the application are true.
SWORN (OR AFFIRMED) BEFORE ME in
) | ||
the _______________________ | of ______________________________ | ) |
(City, etc.) | ) | |
) | ||
) |
in the_____________________ | of ___________________ | ) | |
(Province, etc.) | ) | ______________________ | |
) | (Signature of Deponent) |
) | |||
on this __________ | day of ______________________ , | _________________. | ) |
(Month) | (Year) | ) | |
) | |||
) |
_________________________________________________________________ | ) |
(Signature of Commissioner, of Oaths, Notary Public or | ) |
other official authorized by law to administer oaths) | ) |
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.