Form 7A - Application for transfer/change of status [F - Rescinded]

Form 7A

Application for Transfer / Change of Status

Check one (/)             Securities Act []              Commodity Contract Act []

FOR INTERNAL USE ONLY

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APPLICATION APPROVED BY DATE APPROVED

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Name of Applicant:

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Residential address (Include Postal Code):

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Name of employer:

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Address where Applicant will be working (Include Postal Code):

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Address for service in the Province (Include Postal Code):

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Applying for registration as:

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[] TRANSFER                 [] CHANGE OF STATUS

A. TRANSFER

Name of previous employer:

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Date of termination:

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B. CHANGE OF STATUS

CURRENT REGISTRATION:

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Applicable examination written
(Attach proof of passing): Date passed:

_________________________ ____________________

__________________________ ____________________

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HAVE THERE BEEN CHANGES IN THE INFORMATION GIVEN IN QUESTIONS 11 THROUGH 20 (SEE REVERSE) OF THE UNIFORM APPLICATION FOR REGISTRATION / APPROVAL PREVIOUSLY FILED BY YOU AND APPROVED?

CIRCLE ONE: YES / NO. IF YES, ATTACH FULL PARTICULARS.

The undersigned hereby certify that the foregoing statements are true and correct to the best of our knowledge, information and belief (after having seen the Uniform Application for Registration / Approval and all subsequent Applications for Transfer / Change of Status previously filed by the applicant) and we hereby undertake to notify the British Columbia Securities Commission in writing, of any change therein within the period prescribed by the British Columbia Securities Act, Commodity Contract Act or regulations of either Act.

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Date Signed                                          Signature of Applicant

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Print Name of Partner, Director or      Signature of Partner, Director of Officer
Officer of the Dealer, Adviser or
Underwriter that employs the Applicant

CHANGE OF NAME

PRIOR REGISTRATION OR LICENSING

REFUSAL, SUSPENSION, CANCELLLATION OR DISCIPLINARY MEASURE

SELF - REGULATORY ORGANIZATIONS

OFFENCES UNDER THE LAW

CIVIL PROCEEDINGS

BANKRUPTCY

JUDGMENT OR GARNISHMENT

SURETY BOND OR FIDELITY BOND

BUSINESS ACTIVITIES