Securities Law

31-902F - Uniform application for registration / approval (BC) [F - Rescinded]

Published Date: 2001-03-30
Effective Date: 2001-03-28
Rescinded Date: 2003-03-28

UNIFORM APPLICATION FOR

REGISTRATION /APPROVAL (B.C.)

BC FORM 31 -902F

(Previously Form 4)

FOR INTERNAL USE ONLY 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 of or use of the information can be directed to the Registration Supervisor, Registration and Market Regulation Branch, Capital Markets Regulation Division, British Columbia Securities Commission, PO Box 10142,Pacific Centre, 701 West Georgia Street, Vancouver BC V7Y 1L2. Telephone (604) 899-6692. Toll Free within British Columbia 1-800-373-6393.

INSTRUCTIONS

  1. 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, adviser or underwriter to a Canadian Securities Commission or similar authority.

  2. This form may also be used by any individual submitting an application for registration as an adviser to a Canadian Securities Commission or similar authority.

  3. All applicable questions must be answered. Failure to do so may cause delays in the processing of the application.

  4. This form and all attachments added thereto must be typewritten, printed legibly in ink or prepared on an approved computer-generated form. Any form or attachment completed by any other means may be considered not properly filed.

  5. 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.

  6. In completing the application, applicants should seek advice from an authorized officer of the sponsoring firm or from a legal adviser, if necessary.

  7. 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.

  8. Applicants for registration in Quebec need only disclose information for the past 10 years in respect of Questions 15B, 15D, 17A, 17B, 18 and 19.

  9. This form has been modified to conform with amendments to securities legislation in British Columbia. If you wish to file this form other than with the British Columbia Securities Commission please contact the self-regulatory organization and/or Securities Regulatory Authority prior to filing with them.

1. APPLICANT

LAST NAME                                              FIRST, SECOND AND THIRD NAMES - if applicable

 

RESIDENTIAL ADDRESS                      POSTAL CODE

 

TELEPHONE NUMBER                    FAX NUMBER                  E-MAIL/INTERNET ADDRESS                  SOCIAL INSURANCE NUMBER
                                                                                                                                                                                 (Not required for applications in Ontario)

ADDRESS FOR SERVICE IN BRITISH COLUMBIA                                                                                        POSTAL CODE

 

PRESENT POSITION IN THE FIRM                                                                                                                    COMMENCED EMPLOYMENT ON

 

2.FIRM

NAME

TELEPHONE NUMBER                              FAX NUMBER                   E-MAIL/INTERNET ADDRESS

 

ADDRESS WHERE APPLICANT WILL BE WORKING                                                                                    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 or regulation and in by-laws, rules and regulations of exchanges, the Investment Dealers Association of Canada and other self-regulatory organizations.

TYPE OF INSTRUMENTS

TYPE OF REGISTRATION

Securities (Other than Forward Contracts)
Exchange Contracts
Forward Contracts
Mutual Fund Securities
Scholarship Plan Securities
Real Estate Securities
Security Issuer Securities
Other (specify) _______________

Salesperson
Partner
Director
Officer (title) ___________________

- Trading/Advising
- Non-Trading/Advising
- Compliance Officer

Branch Manager
Director, Investor, or Officer of approved affiliated company (delete designation not applicable)
Industry Investor
Non-Industry Investor
Portfolio Manager
Investment Counsel
Securities Adviser
Advising Employee
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

Prince Edward Island

British Columbia

Newfoundland

Nunavut

Quebec

Manitoba

Northwest Territories

Ontario

Saskatchewan
Yukon Territory

SELF-REGULATORY ORGANIZATIONS

Bourse de Montréal (Montreal Exchange)

Toronto Stock Exchange

Canadian Venture Exchange (CDNX)

Winnipeg Commodity Exchange

Investment Dealers Association of Canada

Other (specify)_____________________

Mutual Fund Dealers Association of Canada

 

5.PERSONAL DESCRIPTION OF APPLICANT

DATE OF BIRTH                          PLACE OF BIRTH                                                                           GENDER

YY /MM /DD                                   CITY                                 PROVINCE       COUNTRY

 

HEIGHT    WEIGHT    COLOUR OF EYES    COLOUR OF HAIR    NAME OF SPOUSE AND NATURE OF HIS/HER EMPLOYMENT

 

CITIZENSHIP

 

If NOT a Canadian Citizen, answer the following

ARE YOU A PERMANENT RESIDENT?

NUMBER OF YEARS OF CONTINUOUS RESIDENCE IN CANADA

PASSPORT INFORMATION

   

YES
NO

 

COUNTRY

PLACE OF ISSUE

DATE OF ISSUE

PASSPORT NUMBER

6. PHOTOGRAPH

INSTRUCTION: Attach hereto two copies of a 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: NAME OF LAST SCHOOL ATTENDED IN EACH LEVEL                         DEGREE OR DIPLOMA                    DATE OBTAINED

High School or Secondary Level

Post-Secondary, College, CEGEP or University

Professional Education

Other

Have you successfully completed:                                                                   YES     NO          EXEMPT*                 DATE COMPLETED
                                                                                                                                                                                                          YY /MM /DD

ACE Traders Exam
Branch Compliance Officer's Course (ICB)
Branch Managers'Examination (IFIC)
Branch Managers Qualifying Exam (CSI)
Canadian Commodity Futures Examination (CSI)
Canadian Commodity Supervisors Exam (CSI)
Canadian Futures Exam Program (CSI),Part I
Canadian Futures Exam Program (CSI),Part II
Canadian Investment Finance Course (CSI),Part I
Canadian Investment Finance Course (CSI),Part II
Canadian Investment Funds Course (IFIC)
Canadian Investment Management (CSI),Part I
Canadian Investment Management (CSI),Part II
Canadian Operations Course (CSI)
Canadian Options Course (CSI)
Canadian Securities Course (CSI)
CATS Exam - Oral,,Written
Chartered Financial Analysts Course (AIMR),(1st Year)
Chartered Financial Analysts Course (AIMR),(2nd Year)
Chartered Financial Analysts Course (AIMR),Complete
Conduct and Practices Handbook Exam (CSI)
Derivatives Fundamentals Course (CSI)
Effective Management in the Securities Industry Course (CSI)
Examination Based on Manual for Registered Representatives (CSI)
Fundamentals of Portfolio Management Course (CSI)
Futures Licensing Exam (CSI)
Investment Funds in Canada Course (ICB)
Investment Management Techniques Course (CSI)
National Commodities Futures Examination
New Entrants'Examination (CSI)
Officers',Partners'or Directors'Examination (IFIC)
Options Licensing Course (CSI)
Options Supervisors Course (CSI)
Partners,Directors and Senior Officers Qualifying Exam (CSI)
Portfolio Management Techniques Course (CSI)
Principals of Mutual Fund Investments
Professional Financial Planning Course (CSI)
Qualifying Examination for Registered Options Principal
Real Estate Pre-Licensing Course (UBC)
Real Estate Securities Course (UBC)
Registered Options Principals Exam Program (CSI)
Technical Analysis Course
Trader Training Course (CSI)
VCT Examination
Wealth Management Techniques (CSI)
Other (Specify) ___________________________________________
*If you have been granted exemption, attach full particulars.
Have you ever applied for and been refused exemptions from any of the above listed examination requirements? (If so, give particulars as an attachment). YES NO

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 ADDRESS OF EMPLOYER

NAME AND TITLE OF
IMMEDIATE SUPERIOR

NATURE OF EMPLOYMENT
AND DUTIES OF APPLICANT

REASONS FOR
LEAVING

FROM
YY /MM YY /MM

TO
YY /MM YY /MM

PRESENT

     
      
      

PREVIOUS

     
      
      

B. Have you ever been discharged by an employer for cause? Check as applicable.

(If yes, give particulars as an attachment). YES NO

9. RESIDENTIAL HISTORY - give all home addresses for the past 10 years. Include street, city, province.

PRESENT                                                                          POSTAL CODE                                      FROM                     TO
                                                                                                                                                               YY /MM                    YY /MM

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).

NAME                                       FIRM NAME                                   BUSINESS ADDRESS - include postal code                      OCCUPATION
                                                                                                          TELEPHONE - include area code 

 

 

 

Account No. at reference bank or trust company

NOTE: Account No. need not be given if this form is accompanied by a written reference from a bank or trust company 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. Please ()
                                                                                                                                                             YES OR 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 or exchange contracts (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 or exchange contracts (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 in securities or exchange contracts (commodities or commodity futures contracts)in any province, territory, state or country?

QUESTIONS 13 TO 18 INSTRUCTION:In answering Questions 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 or exchange contracts (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 a limited dealer -security 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 or exchange contracts (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 than trading in securities or exchange contracts (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 or exchange contracts (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 or exchange contracts (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 or exchange contracts (commodities or commodity futures contracts)?

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.Please ()

YES OR NO

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 or exchange contracts exchange (commodities exchange or commodity futures exchange), association of investment dealers, investment bankers, brokers, broker-dealers, mutual fund dealers, exchange contracts dealer (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 14A?

15.OFFENCES UNDER THE LAW

INSTRUCTION: Offences under such federal statutes as the Income Tax Act (Canada) and the Immigration Act (Canada) constitute criminal offences and must be disclosed when answering this question. 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.

It should be noted that pleas or findings of guilt for impaired driving are Criminal Code (Canada) matters and must be disclosed.

You are not required to disclose any offence for which a pardon has been granted under the Criminal 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, Commodities, Insurance or Real Estate

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, exchange contracts (commodities or commodity futures contracts), insurance or real estate 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 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?

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?

 

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. Please ()

YES OR NO

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 Civil Code 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, territory, 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 or exchange contracts (commodities or commodity futures contracts)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 (e.g., 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.

NAME OCCUPATION

 

ADDRESS POSTAL CODE

 

 

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, RULES 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. We understand that we are obligated to notify the Securities Commissions or similar authorities marked in Question 4 in writing of any material change therein as prescribed by the applicable securities and/or commodity futures legislation and we hereby undertake to notify any self-regulatory organization marked in Question 4 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 securities and/or commodity futures legislation, regulations, rules and policy statements of the Securities Commissions or similar authorities marked in Question 4 and that we are conversant with the by-laws, rulings, rules and regulations of the self-regulatory organizations marked in Question 4.

We understand that we are obligated to observe and comply with the securities and/or commodity futures legislation, regulations, rules and policy statements of the Securities Commissions or similar authorities marked in Question 4 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 understand that any approval granted pursuant to this application may be revoked, terminated or suspended at any time in accordance with the then-applicable securities and/or commodity futures legislation, regulations, rules and policy statements.

We agree, if the undersigned sponsoring firm is a member of the self-regulatory organizations marked in Question 4,to be bound by and to observe and comply with the by-laws, rulings, rules and regulations of the self-regulatory organizations 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 marked in Question 4 and, wherever applicable, the Governors, Directors and the 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 revocation or termination, the undersigned applicant agrees forthwith to terminate the applicant ’s associations 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 marked in Question 4 or any approved affiliated company or other affiliate of 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 any of the self-regulatory organizations listed in Question 4 of this application form in the event that some time in the future the undersigned applicant applies to such self-regulatory organization.

The undersigned applicant has discussed the questions in this application and in particular Question 15 and 16 with a compliance 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 or Securities Commissions or similar authorities marked in Question 4 may obtain any information whatsoever from any source, as permitted by law in any jurisdiction in Canada or elsewhere.

Dated at ____________________________ this _______ day of _________ _______

(Day) (Month) (Year)

 

 

_________________________________ _________________________________

(Signature of Applicant) (Name of Sponsoring Firm)

By _____________________________

(Partner or Authorized Officer)

 

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 have read and understand the questions and the "Caution" in this application.

2. The answers I have given to the questions in this application and in any attachments to it are true.

3. 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.

4.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.)

____________________________________

(Signature of Commissioner of Oaths, Notary Public or other official authorized by law to administer oaths)

on this ___________ day of _______________, _______

(Month), (Year).

It is an offence under the Securities Act to file an application containing a statement that, at the time and in light of the circumstances in which it is made, is a misrepresentation.

FIN 31-902 Rev. 2001/3/30