Form 4B - Personal Information for Directors, Officers, Promoters & Control Persons [F - Rescinded]
| Published Date: | 1992-07-10 |
|---|---|
| Effective Date: | 1992-09-01 |
| Rescinded Date: | 1996-09-01 |
Form 4B
Personal Information for Directors, Officers, Promoters & Control Persons
____________________________________________ The personal information requested on this form is collected under the authority of and used for the purpose of administering theSecurities Act. Questions about the collection of or use of the 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 Columbia1-800-373-6393. | ________________________________ ________________________________ DATE _____________________ DISCLOSURE [] YES [] NO FOREIGN ENQUIRY [] UPDATE [] ______________ ________________________________ |
INSTRUCTIONS:
- Application Every director, officer, promoter and control person of an issuer must file this form when required to do so pursuant to section 90 of the Securities Act or any rule, notice or policy statement issued or made by the Commission.
- Completion of form This form and any attachment to it must be typewritten, printed legibly in ink, or prepared on an approved computer generated form. Enter "N/A" ("not applicable") where appropriate.
- Solemn declaration and attachments The official before whom this form is declared must mark as exhibits and initial any attachments to this form. Persons completing this form must also initial any attachments. This form and any attachments must contain original signatures or initials as appropriate.
- Legal advice Persons required to complete this form should consider seeking legal advice.
- Where to file On completion of this form, file it with:
British Columbia Securities Commission
200 865 Hornby Street
Vancouver, B.C.
V6Z 2H4
DEFINITIONS:
Unless otherwise indicated, terms used in this form have the same meaning as in the Securities Act, S.B.C. 1985, c. 83 and the Securities Regulation, B.C. Reg. 479/95.
In this form:
"director" includes a director of a general partner of a limited partnership;
"issuer" includes a general partner of a limited partnership;
"officer" includes an officer of a general partner of a limited partnership.
In questions 8 to 12 inclusive of this form:
"guilty", in relation to a plea or a finding, includes an absolute or conditional discharge;
"offence" means
a) a summary conviction or indictable offence under the Criminal Code (Canada),
b) a misdemeanour or felony under the criminal legislation of the United States of America or of any state or territory of the United States of America,
c) an offence under the criminal legislation of any jurisdiction other than Canada, the United States of America or a state or territory of the United States of America,
d) a quasi-criminal offence, for example under the Income Tax Act (Canada) or the tax legislation of any other jurisdiction, the Immigration Act (Canada) or the immigration legislation of any other jurisdiction, or the Securities Act (British Columbia) or the securities legislation of any other jurisdiction,
and excludes
e) an offence for which a pardon has been granted and has not been revoked under the Criminal Records Act (Canada) or the comparable legislation of any other jurisdiction, and
f) an offence under the motor vehicle legislation of any jurisdiction;
"securities regulatory authority" means a body created by statute in any jurisdiction to administer securities law and policy but does not include a stock exchange or other self regulatory organization.
"self regulatory" organization means
a) a stock, commodities, futures or options exchange,
b) an association of investment, securities, mutual fund, commodities, or futures dealers,
c) an association of investment counsel or portfolio managers,
d) an association of other professionals, for example legal, accounting, engineering, and
e) any other self regulatory organization.
CAUTION A person who makes a false statement by statutory declaration commits an indictable offence under the Criminal Code that is punishable by imprisonment for a term not exceeding fourteen years. | ___________________________________ ___________________________________ ___________________________________ |
________________________________________________________________
- IDENTIFICATION
LAST NAME FIRST, SECOND AND THIRD NAMES
_________________________________________________________________
ADDRESS FOR SERVICE IN BRITISH COLUMBIA - Include postal code
_________________________________________________________________
ISSUER'S NAME
_________________________________________________________________
PRESENT POSITION WITH THE ISSUER - check (x) as applicable
[] DIRECTOR [] PROMOTER
[] OFFICER [] CONTROL PERSON
_________________________________________________________________
IF DIRECTOR/OFFICER DATE ELECTED/APPOINTED IF OFFICER - TITLE
Y M D
_________________________________________________________________ - EDUCATIONAL HISTORY - Provide your educational history starting with the most recent. Include secondary education.
SCHOOL LOCATION DEGREE OR DIPLOMA DATE OBTAINED
Y M D
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
PROFESSIONAL DESIGNATION - Provide any professional designations held, for example, Barrister & Solicitor, C.A., CMA, C.G.A., P. Eng., and P. Geo., and indicate by whom and the date the designations were granted.
PROFESSIONAL GRANTER OF DATE GRANTED IN EFFECT -
DESIGNATION DESIGNATION Y M D YES OR NO
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________ - EMPLOYMENT HISTORY - Provide your employment history for the 10 years immediately prior to the date of this form starting with your current employment.
EMPLOYER EMPLOYER POSITION HELD FROM TO
NAME ADDRESS Y M Y M
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Provide any legal names, other than the name given in 1, and FROM TO
assumed names under which you have carried on business Y M Y M
or otherwise been known.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________ - PHOTOGRAPH
Attach to this form two identical black and white photographs, full face, taken within the last 6 months showing a true likeness of yourself as you now appear. The photographs must measure 2" x 2", be of passport quality and bear on the back the date on which they were taken, your signature and the signature of a Commissioner of Oaths, Notary Public or other official authorized by law to administer oaths.
_________________________________________________________________ - PERSONAL INFORMATION
RESIDENTIAL TELEPHONE BUSINESS TELEPHONE FAX E-MAIL
NUMBER NUMBER NUMBER (INTERNET)
area code area code area code
_________________________________________________________________
DATE OF BIRTH PLACE OF BIRTH CITY PROVINCE/STATE COUNTRY
Y M D
_________________________________________________________________
SEX HEIGHT WEIGHT COLOUR COLOUR DISTINGUISHING
[] MALE [] FEMALE OF EYES OF HAIR CHARACTERISTICS
- if any
_________________________________________________________________
MARITAL STATUS FULL NAME OF SPOUSE OCCUPATION OF SPOUSE
- include common - law
_________________________________________________________________
CITIZENSHIP
If you are not a Canadian citizen, are you a permanent resident of Canada? [] YES [] NO
Number of years of continuous residence in Canada: Years
_________________________________________________________________
PASSPORT NAME OF CITY WHERE DATE PASSPORT PASSPORT
COUNTRY PASSPORT WAS ISSUED ISSUED NUMBER
OF ISSUE Y M D
_________________________________________________________________
DRIVER'S LICENCE PROVINCE/STATE WHERE SOCIAL INSURANCE/
NUMBER DRIVER'S LICENCE WAS ISSUED SECURITY NUMBER
_________________________________________________________________ - RESIDENTIAL HISTORY - Provide all residential addresses for the past 10 years starting with your current principal residential address.
STREET ADDRESS, CITY, PROVINCE/STATE, COUNTRY FROM TO
& POSTAL/ZIP CODE Y M Y M
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________ - POSITIONS IN OTHER ISSUERS
Provide the names of reporting issuers in British Columbia and of issuers with continuous disclosure obligations in other jurisdictions of which you are now, or within the past five years have been, a director, officer, promoter or control person, the positions you held and the periods during which you held those positions. Use attachment if necessary.
NAMES OF POSITIONS HELD FROM TO
(REPORTING) ISSUERS WITH ISSUER Y M Y M
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
INSTRUCTIONS for Questions 8 to 12 inclusive - answer" yes" or" no" in the space provided.
Refer to the definitions on the first page of this form, if your answer to any of questions 8 to 12 is "yes", you must, in an attachment, give complete details including the circumstances, relevant dates, names of the parties involved and final disposition, if known. - OFFENCES YES/NO
A. OFFENCES
Have you pleaded guilty to or been found guilty of an offence? _____
B. CURRENT CHARGES, INDICTMENTS OR PROCEEDINGS
Are you the subject of a current charge, indictment or proceeding for an offence? _____ - ADMINISTRATIVE PROCEEDINGS
A. PROCEEDINGS BY SECURITIES REGULATORY AUTHORITY
Has a securities regulatory authority:
a) prohibited or disqualified you under securities or corporate legislation from acting as a director or officer of an issuer? _____
b) refused to register or license you to trade securities or restricted, suspended or cancelled your registration or licence? _____
c) refused to issue a receipt for a prospectus or other offering document solely or partially as a result of your being associated with that issuer? _____
d) issued a cease trading or similar order against you? _____
e) issued an order that denied you the right to use any statutory exemptions? _____
f) taken any other proceeding against you? _____
B. PROCEEDINGS BY SELF REGULATORY ORGANIZATION
Have you been reprimanded, suspended, fined or otherwise disciplined, in any jurisdiction, by a self regulatory organization? _____
C. CURRENT PROCEEDINGS BY SECURITIES REGULATORY AUTHORITY OR SELF REGULATORY ORGANIZATION
Are you now the subject, in any jurisdiction, of:
a) a notice of hearing or similar notice issued by a securities regulatory authority? _____
b) a proceeding by a self regulatory organization? _____
D. SETTLEMENT AGREEMENT
Have you entered into a settlement agreement with a securities regulatory authority, a self regulatory organization or an attorney general or comparable official in any jurisdiction in a matter that involved actual or alleged fraud, theft, deceit, misrepresentation, insider trading, unregistered trading, unregistered distributions, failure to disclose material facts or changes or similar conduct by you, or involved any other violation of securities legislation or a self regulatory organization's rules? _____
E. SUSPENSION OR TERMINATION OF EMPLOYMENT
Has a registered dealer, in any jurisdiction, suspended or terminated your employment with the dealer for cause? _____ - CIVIL PROCEEDINGS
A. JUDGMENT, GARNISHMENT AND INJUNCTIONS
Has a civil court in any jurisdiction:
a) rendered a judgment or ordered garnishment against you in a civil claim based in whole or in part on fraud, theft, deceit, misrepresentation, insider trading, unregistered trading, unregistered distributions, failure to disclose material facts or changes or similar conduct? _____
b) issued an injunction or similar ban against you by consent or otherwise in a civil claim described in question a)? _____
B. CURRENT CLAIMS
Are you now the subject, in any jurisdiction, of a civil claim that is based in whole or in part on actual or alleged fraud, theft, deceit, misrepresentation, insider trading, unregistered trading, unregistered distributions, failure to disclose material facts or changes or similar conduct? _____
C. SETTLEMENT AGREEMENT
Have you entered into a settlement agreement, in any jurisdiction, in a civil action that involved actual or alleged fraud, theft, deceit, misrepresentation, insider trading, unregistered trading, unregistered distributions, failure to disclose material facts or changes or similar conduct on your part? _____ - PERSONAL BANKRUPTCY
Have you in any jurisdiction:
a) had a petition in bankruptcy issued against you 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 proceeding arrangement or compromise with creditors? _____
d) had a receiver, receiver manager or trustee appointed to hold your assets? _____
Are you now an undischarged bankrupt? _____
If you answered "yes" to any of questions a) to d), and if applicable, attach a copy of any discharge, release or other document that has a similar effect. - PROCEEDINGS AGAINST ISSUER
To the best of your knowledge, were you a director, officer, promoter, or control person of an issuer, in any jurisdiction, at the time of events that led to:
a) the issuer pleading guilty to, or being found guilty of, an offence based in whole or in part on fraud, theft, deceit, misrepresentation, insider trading, unregistered trading, unregistered distributions, failure to disclose material facts or changes or similar conduct? _____
b) a pending charge, indictment or proceeding against the issuer, for an offence described in question a)? _____
c) a securities regulatory authority:
i) refusing, restricting, suspending or cancelling the registration or licencing of the issuer to trade securities? _____
ii) issuing a cease trading or similar order against the issuer, other than an order for failure to file financial statements that was revoked within 30 days of its issuance? _____
iii) issuing an order that denied the issuer the right to use any statutory exemptions? _____
iv) taking any other proceeding against the issuer? _____
v) issuing a current notice of hearing or similar notice against the issuer? _____
d) a reprimand, suspension, fine or disciplinary action of the issuer by a self regulatory organization? _____
e) a current proceeding against the issuer by a self regulatory organization? _____
f) a civil court:
i) rendering a judgment or ordering garnishment in a claim against the issuer based in whole or in part on fraud, theft, deceit, misrepresentation, insider trading, unregistered trading, unregistered distributions, failure to disclose material facts or changes or similar conduct? _____
ii) issuing an injunction or similar ban against the issuer by consent or otherwise in a claim described in question i)? _____
g) a current civil claim against the issuer that is based in whole or in part on actual or alleged fraud, theft, deceit, misrepresentation, insider trading, unregistered trading, unregistered distributions, failure to disclose material facts or changes or similar conduct? _____
h) the issuer entering a settlement agreement with a securities regulatory authority, a self regulatory organization or an attorney general or comparable official in any jurisdiction in a matter that involved actual or alleged fraud, theft, deceit, misrepresentation, insider trading, unregistered trading, unregistered distributions, failure to disclose material facts or changes or similar conduct by the issuer, or involved any other violation of securities legislation or a self regulatory organization's rules? _____
i) the issuance of a petition in bankruptcy against the issuer or a voluntary assignment in bankruptcy? _____
j) a proposal by the issuer under any legislation relating to bankruptcy or insolvency? _____
k) proceedings against the issuer under any legislation relating to winding up, dissolution or companies' creditors arrangements? _____
l) a proceeding, arrangement or compromise by the issuer with creditors? _____
m) the appointment of a receiver, receiver manager or trustee to hold the issuer's assets? _____
Is an issuer in any jurisdiction of which you are now a director, officer, promoter or control person, now an undischarged bankrupt? _____
If you answered "yes" to any of questions i) to m), and if applicable, attach a copy of anydischarge, release or other document that has a similar effect.
_______________________________________________________________________
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:
- I have read and understand the questions and the "Caution" in this application.
- The answers I have given to the questions in this application and any attachments to it are true.
- I consent to the information in this application being used to conduct an investigation, including a criminal records check, regarding my suitability to act as director, officer, promoter or control person.
- I understand that failure by me to disclose information accurately about my criminal history, if any, may constitute an offence under the provincial or territorial Securities Act or equivalent, or under the Criminal Code (Canada).
SWORN (OR AFFIRMED) BEFORE ME in
the _______________ | of _________________ | ) | _______________________ |
(City, etc.) | ) | (Signature of Deponent) | |
) | |||
in the______________ | of _________________ | ) | |
(Province, etc.) | ) | ||
) | _________________________ | ||
on this _____________ day of | ___________ , _________ | ) | (Signature of Commissioner, of Oaths, Notary Public orother official authorized by law to administer oaths) |
(Month) (Year) | ) |