Form 4Z - Consent to a criminal records check [F - Rescinded]
| Published Date: | 1997-06-20 |
|---|---|
| Effective Date: | 1997-07-31 |
| Rescinded Date: | 2001-03-28 |
FORM 4Z
Consent to a criminal records check
_________________________________________________________________
INSTRUCTION
- Individuals that carry on registrable activities for registered dealers, underwriters and advisers that have their principal place of business in Canada in a jurisdiction outside British Columbia, or that are members of an exchange or self regulatory body in Canada, may file a form corresponding to Form 4 that is not in the form specified by the Executive Director. That is, they may file a corresponding form required by the jurisdiction in which the dealer, underwriter or adviser carries on its principal business or by the exchange or self regulatory body of which the dealer, underwriter or adviser is a member. Where this is the case and the form does not include a declaration of consent to a criminal records check, the individual must also file a completed Form 4Z "Consent to a Criminal Records Check", signed by the individual and sworn before a commissioner of oaths.
- Please provide all information and date and sign this acknowledgment.
_________________________________________________________________
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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NAME OF APPLICANT
SURNAME GIVEN NAME(S) MAIDEN NAME - if applicable GENDER - please (x) one
o male o female
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MAILING ADDRESS CITY PROVINCE POSTAL CODE
_________________________________________________________________
BIRTHDATE BIRTHPLACE IF FOREIGN BORN, (YY/MM/DD)
(YY/MM/DD) INDICATE DATE OF ENTRY
_________________________________________________________________
HEIGHT WEIGHT HAIR COLOUR EYE COLOUR
_________________________________________________________________
Have you ever been convicted under the law of any Province, State or Country from which you have not been pardoned? - please (x) appropriate one
o NO o YES - If yes, please submit full details of those offences.
_________________________________________________________________
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 consent to the information in my application for registration or for approval or renewal or reinstatement of registration being used to conduct a suitability investigation, including a criminal records check, regarding my application.
2. 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) | ) |
_____________________________________________________________________
COMMISSION USE ONLY FILE NUMBER_____________________________________
IS A FOREIGN ENQUIRY REQUESTED?
oNo oYes - if yes, please submit foreign resident/business history on an attachment.
If the check performed by the Royal Canadian Mounted Police reveals a failure by the applicant to accurately disclose the applicant's criminal history, release of the applicant's criminal record is hereby requested for the purpose of conducting an investigation of an offence: such release being authorized by Section 8 (2) (a) of the Privacy Act (Canada).
______________________ Dated this _________ day of ______________ _________
(Signature of Commission Official) (Day) (Month) (Year)
_______________________________________________________________________
SECURITIES FRAUD INFORMATION CENTER (SFIC) USE ONLY
SFIC FILE NUMBER CRIMINAL RECORD FOR FPS NUMBER
_______________________________________________________________________
YES NO YES NO
RCMP FILE o o CRIMINAL RECORD IS AS DISCLOSED o o
CRIMINAL RECORD o o FOREIGN ENQUIRIES BEING CONDUCTED o o
_______________________ Dated this _________ day of ____________ _________
(Signature of Officer) (Day) (Month) (Year)