Form 4 - Uniform application for registration/approval [F - Rescinded]
| Published Date: | 1998-07-24 |
|---|---|
| Effective Date: | 1998-07-22 |
| Rescinded Date: | 2001-04-26 |
Form 4
Uniform Application for Registration/Approval
Check one: Securities Act ............. Commodity Contract Act .............
Instructions
- 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, broker, adviser or underwriter to a Canadian Securities Commission or similar authority.
- This form may also be used by any individual submitting an application for registration as a dealer, broker or adviser to a Canadian Securities Commission or similar authority.
- All applicable questions must be answered. Failure to do so may cause delays in the processing of the application.
- This form and all attachments added thereto must be typewritten. Any form or attachment completed by any other means may be considered not properly filed.
- 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.
- In completing the application, applicants should seek advice from an authorized officer of the sponsoring firm or from a legal adviser, if necessary.
- 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.
- Applicants for registration in Quebec need only disclose information for the past 10 years in respect of Questions 15(B), 15(D), 17(A), 17(B), 18 and 19.
FOR INTERNAL USE ONLY
_______________________________________________
Application approved by Date
_______________________________________________
1. APPLICANT:
_________________________________________________________________
Last Name First, Second & Third Names
_________________________________________________________________
Residential address (with postal code) Area Code:
Telephone:
_________________________________________________________________
Address for service in British Columbia (with postal code) Social Insurance Number (not
required for applications in
Ontario)
_________________________________________________________________
Present position in the firm Commenced employment on
Year Month Day
_________________________________________________________________
2. FIRM:
_________________________________________________________________
Name Area code:
Telephone:
_________________________________________________________________
Address where applicant will be working (with 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, commodity contract act, or regulation and in by-laws, rules and regulations of exchanges, the Investment Dealers Association of Canada and other self-regulatory organizations. Applicants filing for restricted registration should file under OTHER, specifying the nature of the restricted registration applied for.
_________________________________________________________________
| REGISTERED REPRESENTATIVE OR SALESPERSON REGISTRATION: | OTHERS: |
[] Securities | [] Partner [] Director [] Officer (title) _____________ -- Trading [] -- Non-Trading [] -- Counselling [] [] Branch manager [] Director, Investor, or Officer of approved affiliated company (delete designation not applicable) [] Industry Investor [] Non-Industry Investor [] Portfolio Manager [] Designated/Alternate Registered Options Principal [] Designated/Alternate Registered Futures Principal [] Designated/Alternate Registered Futures Options Principal [] 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 | |||
| [] Alberta | [] New Brunswick | [] Nova Scotia | [] Quebec |
| [] British Columbia | [] Newfoundland | [] Ontario | [] Saskatchewan |
| [] Manitoba | [] Northwest Territories | [] Prince Edward Island | [] Yukon Territory |
SELF-REGULATORY ORGANIZATIONS | |||
| [] Alberta Stock Exchange | [] Toronto Stock Exchange | ||
| [] Investment Dealers Association of Canada | [] Vancouver Stock Exchange | ||
| [] Montreal Exchange | [] Winnipeg Commodity Exchange | ||
| [] Toronto Futures Exchange | [] Winnipeg Stock Exchange | ||
| [] Other (specify) ___________ | |||
_________________________________________________________________
5. PERSONAL DESCRIPTION OF APPLICANT:
(A) DATE OF BIRTH PLACE OF BIRTH Sex
Year Month Day City Province Country
_________________________________________________________________
Height Weight Colour of eyes Colour of hair Name of spouse & nature
of his/her employment
_________________________________________________________________
Citizenship If NOT a Canadian Citizen,
answer question 5(B) below.
_________________________________________________________________
(B) Are you a Number of years Passport
permanent of continuous Country Place Date Number
resident? residence in Canada of issue of issue
_________________________________________________________________
6. PHOTOGRAPH:
INSTRUCTION: Attach hereto two copies of a black and white 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 or branch manager of the sponsoring firm.
7. EDUCATION:
(A) INSTRUCTION: State the last school Degree or Diploma Date Obtained
attended in each level.
_________________________________________________________________
High School or
Secondary Level
_________________________________________________________________
Post-Secondary,
College, CEGEP
or University
_________________________________________________________________
Professional Education
_________________________________________________________________
Other
_________________________________________________________________
| Have you successfully completed: | Date | |||
| Yes | No | Exempt* | Completed | |
| Canadian Securities Course | [] | [] | [] | ______ |
Examination based on Manual for Registered Representatives | [] | [] | [] | ______ |
Partners/Directors/Officers Qualifying Examination | [] | [] | [] | ______ |
| Canadian Investment Finance (course 2): | ||||
Part I | [] | [] | [] | ______ |
Part II | [] | [] | [] | ______ |
| F.C.S.I. | [] | [] | [] | ______ |
| Chartered Financial Analyst Course | [] | [] | [] | ______ |
Qualifying Examination for Registered Options Principal | [] | [] | [] | ______ |
| Canadian Options Course | [] | [] | [] | ______ |
| Canadian Investment Funds Course | [] | [] | [] | ______ |
| National Commodity Futures Examination | [] | [] | [] | ______ |
| Canadian Commodity Futures Examination | [] | [] | [] | ______ |
| Canadian Futures Examination | [] | [] | [] | ______ |
| Commodity Supervisors Examination | [] | [] | [] | ______ |
| Branch Managers Examination | [] | [] | [] | ______ |
| Other (specify) _______________________________________ | ______ |
_________________________________________________________________
(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) __________________________________
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 Nature of Reasons FROM TO
address of title of employment for Yr. Mo. Yr. Mo.
employer immediate and duties leaving
superior of applicant
__________________________________________________________________
PRESENT:
__________________________________________________________________
__________________________________________________________________
PREVIOUS:
__________________________________________________________________
__________________________________________________________________
(B) Have you ever been discharged by an employer for cause? _________________
(If so, give particulars as an attachment).
__________________________________________________________________
__________________________________________________________________
9. RESIDENTIAL HISTORY: (give all home addresses for the past 10 years)
__________________________________________________________________
Include street, city, province & postal code FROM TO
yr. mo. yr. mo.
__________________________________________________________________
PRESENT:
__________________________________________________________________
PREVIOUS:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
10. 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)
__________________________________________________________________
Business Address (with postal code)
Name Firm Name and Telephone (with area code) Occupation
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Account No. at reference bank or trust co.: ____________________
Note: Account No. need not be given if this form is accompanied by a written reference from a bank or trust co. with which the applicant has an account.
ANSWER "YES" OR "NO" TO EACH OF QUESTIONS 11 TO 20 INCLUSIVE.
IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS "YES",
COMPLETE DETAILS MUST BE ATTACHED BY WAY OF EXHIBIT.
YES/NO
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 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 registration or a licence in any capacity under any act or regulation thereof, regulating trading in securities, 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 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, 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 registration or a licence, under any legislation which requires registration or licensing to deal with the public in any capacity other than trading insecurities, 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 ever been refused registration or a licence, or has your registration or licence been suspended or cancelled, under any act or regulation thereof, regulating trading in securities, 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 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, commodities or commodity futures contracts of any province, territory, state or country? ______
(C) Have you ever been refused registration or a licence, or has your registration or licence been suspended or cancelled, under any legislation which requires registration or licensing to deal with the public in any capacity other thantrading in securities, 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 licensing provided by any act or regulation thereof regulating trading in securities, 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, 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, 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, commodities exchange, commodity futures exchange, association of investment dealers, investment bankers, brokers, broker-dealers, mutual fund dealers, 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 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 as described in question 14(A)? ______
15. OFFENCES UNDER THE LAW
INSTRUCTION: Offences under such federal statutes as theIncome 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 offence for which a pardon has been granted under theCriminal 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 or Commodities --
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, commodities, commodity futures contracts or options 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 -
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 -
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 -
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 orindictment, 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? ______
(B) Against any partnership or company of which you are or were at the time 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 bankruptcy? ______
(b) made a proposal under any legislation relating to bankruptcy or insolvency? ______
(c) been subject to or instituted any proceedings, arrangement or compromise with creditors including, without limitation, produced a declaration under the Quebec Voluntary Deposit 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 bankruptcy? ______
(b) made a proposal under any legislation relating to bankruptcy or insolvency? ______
(c) been subject to proceedings under any legislation relating to the winding up, dissolution or companies' creditors arrangements? ______
(d) been subject to or instituted any proceedings, arrangement or 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 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? ______
If yes, attach name and address of bonding company, and when and why the bond was refused.
(B) Are you presently bonded? ______
20. BUSINESS ACTIVITIES
(A) Will you be actively engaged in the business of the firm with which you are 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 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 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 capital of a partnership or of a company having as its principal business that of a broker, dealer or adviser in securities, commodities, commodity futures contract or options 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, i.e. 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 AND POLICY STATEMENTS OF THE SECURITIES REGULATORY AUTHORITIES AND WITHIN THE TERMS OF THE BY-LAWS, RULINGS, RULES AND/OR REGULATIONS OF ANY ONE 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 and hereby undertake to notify the self-regulatory organization 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 by-laws, rulings, rules and regulations of the self-regulatory organizations listed in Question 4.
We agree to be bound by and to observe and comply with them 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 and, wherever applicable, the Governors, Directors and 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 such revocation or termination, the undersigned applicant agrees forthwith to terminate his/her association 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 or any approved affiliated company or other affiliate of any 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 another of the self-regulatory organizations listed in Question 4 of this application form in the event that at some time in the future the undersigned applicant applies to such other self-regulatory organization.
The undersigned applicant has discussed the questions in this application and in particular Question 15 and 16 with an 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 may obtain any information whatsoever from any source, as permitted by law in any jurisdiction in Canada or elsewhere.
Dated at ____________________ this __________ day of ____________________ 19____
______________________________ __________________________________
(Signature of Applicant) (Name of Sponsoring Firm)
By __________________________________
(Partner or Authorized Officer)
AFFIDAVIT
I, the undersigned applicant, do depose and say that I have read and understand the questions in this application form as well as the answers made by myself thereto and the Caution set out above, and that statements of fact made therein and in the attachments, if any, are true.
Sworn before me _____________________________ __________________________________
(Commissioner of Oaths, etc.) (Signature of Deponent)
at the city of ____________________, Province of ____________________
this __________ day of ____________________ 19__
The Province of Saskatchewan & Manitoba require this affidavit to be sworn before a notary public or barrister or solicitor where the applicant is outside the province at the time of application.
It is an offence under applicable Canadian securities and commodity futures legislation to file an application which contains a statement that, at the time and in light of the circumstances in which it is made, is false or misleading, or which falls to state any material fact.