31-902F - Personal Information Form [Proposed F - Lapsed]
| Published Date: | 2004-06-25 |
|---|---|
| Document(s): |
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FORM 31-902F
Personal Information Form
Italicized terms are defined in the Securities Act or Rules.
Personal Information Form
Italicized terms are defined in the Securities Act or Rules.
1. Contact information
Last name, first, middle:
(a) I am a:
(c) Previous home addresses (last 10 years),
(d) Business address,
(e) Business phone number,
(f) Home phone number,
(g) Cell number,
(h) Fax number,
(i) E-mail address,
(j) If you live outside British Columbia, address for service in British Columbia,
(i) _____ Partner,
(ii) _____ Director,
(iii) _____ Officer,
(iv) _____ Significant Securityholder,
of _______________________________________
Name of applicant or registered dealer or adviser
(b) Home address,(ii) _____ Director,
(iii) _____ Officer,
(iv) _____ Significant Securityholder,
of _______________________________________
Name of applicant or registered dealer or adviser
(c) Previous home addresses (last 10 years),
(d) Business address,
(e) Business phone number,
(f) Home phone number,
(g) Cell number,
(h) Fax number,
(i) E-mail address,
(j) If you live outside British Columbia, address for service in British Columbia,
2. Personal description of Partner,Director,Officer, orSignificant Securityholder
(a) Date of birth,
(b) Place of birth,
(c) Citizenship,
(d) Gender,
(e) If NOT a Canadian citizen, answer the following:
(b) Place of birth,
(c) Citizenship,
(d) Gender,
(e) If NOT a Canadian citizen, answer the following:
(i) _____ I am a permanent resident.
(ii) _____ I have been a permanent resident for this many years.
(ii) _____ I have been a permanent resident for this many years.
(f) Passport Information for those neither Canadian nor permanent residents in Canada:
(i) Country,
(ii) Place of Issue,
(iii) Date of Issue,
(iv) Passport Number,
3. Employment history(ii) Place of Issue,
(iii) Date of Issue,
(iv) Passport Number,
Tell us all about your employment and business activities for the last 10 years. Include periods of self-employment and unemployment. Exclude summer employment while a full-time student but include any summer employment in the securities industry. Note, securities include derivative contracts:
(a) Name of employer,
(b) Address of employer,
(c) Reason(s) for leaving,
(d) Start and end date,
(e) Have you ever been discharged by an employer for cause? If yes, tell us all about what happened in each such situation.
(b) Address of employer,
(c) Reason(s) for leaving,
(d) Start and end date,
(e) Have you ever been discharged by an employer for cause? If yes, tell us all about what happened in each such situation.
4. Name changes
Provide a list of all previous names you have been known by, whether as a result of a legal process or not:
(a) Previous name,
(b) Dates in use,
(b) Dates in use,
5. Regulatory and other history
(a) Regulatory history
Have you, or have any of your affiliates, or has any firm of which you were or are a partner, director, officer, or significant securityholder, ever been:
(i) registered or licensed in any capacity anywhere else to trade in or advise on securities? (Trade and advise are broad terms you should review before answering this question.) For each such license or registration, provide:
(A) Name of regulator that provided the license or registration,
(B) Nature of license or registration,
(C) Jurisdiction of regulator (state, province, territory),
(ii) a partner, director, officer, or significant securityholder of any firm registered or licensed anywhere to trade in or advise on securities? If so, provide:
(A) Name of regulator that provided the license or registration,
(B) Nature of license or registration,
(C) Jurisdiction of regulator (state, province, territory),
(A) Name of registered or licensed firm,
(B) Your relationship to the firm (partner, director, officer, significant securityholder),
(C) Name of regulatory authority,
(D) Nature of firm’s registration or license,
(E) Effective dates of firm’s registration or license,
(B) Your relationship to the firm (partner, director, officer, significant securityholder),
(C) Name of regulatory authority,
(D) Nature of firm’s registration or license,
(E) Effective dates of firm’s registration or license,
(iii) registered or licensed in any other capacity anywhere to deal with the public? (e.g. as an insurance agent, real estate agent, private investigator, mortgage broker, etc.). For each such license or registration, provide:
(A) Name of regulator that provided the license or registration,
(B) Nature of license or registration,
(C) Jurisdiction of regulator (state, province, territory),
(B) Nature of license or registration,
(C) Jurisdiction of regulator (state, province, territory),
(iv) a regulated person of any marketplace, self regulatory organization, or regulatory organization in any jurisdiction? For each such situation, provide:
(A) Name of marketplace, self regulatory organization, or regulatory organization,
(B) Start and end date of membership, participation, or access rights,
(C) Jurisdiction,
(v) refused an application mentioned in 5(a)(i), (ii), (iii), or (iv) above, or been suspended or cancelled?(B) Start and end date of membership, participation, or access rights,
(C) Jurisdiction,
(A) If so, provide date and reasons,
(b)Discipline history
Have you, or have any of your affiliates (Securities Act, s. 1), or has any firm of which you were or are a partner, director, officer, or significant securityholder, ever been disciplined (sanctioned) by any of the regulatory organizations mentioned in (a), above? If so, provide:
(i) Name of regulatory organization that administered the discipline,
(ii) Date,
(iii) Reasons,
(iv) Description of discipline,
(ii) Date,
(iii) Reasons,
(iv) Description of discipline,
(c) Criminal history
Have you, or have any of your affiliates, or has any firm of which you were or are a partner, director, officer, or significant securityholder, ever been convicted of a criminal or quasi-criminal offence? If so, provide:
(i) Name of person convicted,
(ii) Charge,
(iii) Date of conviction,
(iv) Sentence,
Is there a currently outstanding charge or indictment against you, any of your affiliates, or any firm of which you were or are a partner, director, officer, or significant securityholder? If so, provide:
(v) Name of person charged or indicted,
(vi) Description of charge,
(vii) Date set for next appearance in court, and nature of that appearance,
(viii) Court registry name and location,
(d) Civil proceedings
Have you or any of your affiliates, or any firm of which you were or are a partner, director, officer, or significant securityholder, ever been a defendant or respondent in proceedings alleging fraud, theft, deceit, misrepresentation, or similar conduct in any civil court in any jurisdiction? If so, provide:
(i) Name of case,
(ii) Name and location of court registry in which case was heard,
(iii) Outcome of case, whether settled, tried, or appealed,
(e) Solvency(ii) Name and location of court registry in which case was heard,
(iii) Outcome of case, whether settled, tried, or appealed,
Have you or any of your affiliates, or any firm of which you were or are a partner, director, officer, or significant securityholder, ever declared bankruptcy, made a voluntary assignment in bankruptcy, or been petitioned into bankruptcy? If so, provide:
(i) Name of bankruptcy trustee,
(ii) Address of trustee,
(iii) General phone number,
(iv) Start and end date of bankruptcy proceeding,
(v) Description of terms of discharge,
(ii) Address of trustee,
(iii) General phone number,
(iv) Start and end date of bankruptcy proceeding,
(v) Description of terms of discharge,
Have you or any of your affiliates, or any firm of which you were or are a partner, director, officer, or significant securityholder, ever had a receiver or receiver-manager appointed to hold your assets? If so, provide:
(vi) Name of receiver or receiver manager,
(vii) Address of receiver or receiver manager,
(viii) General phone number,
(ix) Start and end date of receivership,
(x) Description of terms completion of receivership,
6. Bonding(vii) Address of receiver or receiver manager,
(viii) General phone number,
(ix) Start and end date of receivership,
(x) Description of terms completion of receivership,
Have you or have any of your affiliates, or any firm of which you were or are a partner, director, officer, or significant securityholder, ever been refused on an application for a surety or fidelity bond? If yes, provide this information:
(a) Name and address of bonding company,
(b) Date of refusal,
(c) Reasons for refusal,
7. Business Activities
A. Will you be actively engaged in the business of the applicant or registrant firm? If so, describe the nature of your activity, whether you will be a trading or advising representative of the firm, and the proportion of your work time that will be spent on the firm’s business.
B. Are you engaged in any other business or do you 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, your title and position, and the amount of time you devote to the business.
If so, attach full details, including the full name and address of the business, your title and position, and the amount of time you devote to the business.
C. In the other business mentioned in B above, are you a partner, director, officer, significant shareholder, or other contributor of capital? If so, attach full details.
8. Security holdings in applicant or registrant firm
For all voting securities in the applicant or registrant firm for which you are or propose to be the beneficial owner after the firm is registered, provide this information:
(a) Number and nature of securities,
(b) Value of securities currently held,
(c) Proportion of ownership securities represent,
(d) Source (treasury, other securityholder, secondary market),
_______________________________________________
Signature of partner, director, officer, or significant securityholder
IT IS AN OFFENCE UNDER THESECURITIES ACTTO FILE AN APPLICATION CONTAINING A STATEMENT THAT IS A MISREPRESENTATION OR TO PROVIDE INFORMATION TO THE BRITISH COLUMBIA SECURITIES COMMISSION THAT IS FALSE OR MISLEADING.