Securities Law

31-904F1 - Uniform Application For Renewal Of Registration [F - Rescinded]

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Rescinded Date: 2003-03-28

BC FORM 31-904F1 (Previously Form 5)

UNIFORM APPLICATION FOR

RENEWAL OF REGISTRATION (BC FORMS 31-901F and 31-902F)

FOR OFFICE USE ONLY

PARTY ID

APPROVED BY

RESTRICTION

PLEASE READ INSTRUCTIONS CAREFULLY

APPLICANT TO COMPLETE ALL SHADED AREAS. CHECK () APPROPRIATE BOXES SHOWN. IF INFORMATION HAS CHANGED, ATTACH AN EXHIBIT GIVING DETAILS.

 

AS NOTED

CHANGED

APPLICANT NAME

  

EMPLOYER NAME

  

BUSINESS ADDRESS

 

  

REGISTRATION OF THE ABOVE IS DUE FOR RENEWAL ON

  

UNDER ACT, AS

  

REGISTRATION FEE

  

APPLICANT LEGAL NAME

  

BUSINESS TELEPHONE FAX NO.

  

SERVICE ADDRESS IN B.C.

 

  

EMPLOYER ID NUMBER

  

RESIDENCE ADDRESS

AND POSTAL CODE

  

() I REQUEST RENEWAL OF THE ABOVE REGISTRATION

() I DO NOT DESIRE RENEWAL OF THE ABOVE REGISTRATION

SEE REVERSE FOR INSTRUCTIONS

 

AMENDMENTS TO INFORMATION - INDIVIDUAL APPLICANT

  

Bankruptcy, judgments, criminal or civil proceedings, since the date of last application or renewal.

  

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

  

You are not required to disclose any offences for which a pardon has been granted under the Criminal Records Act (Canada) and such pardon has not been revoked.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."

A) Have you pleaded guilty or been found guilty under any law of any province, state or country,

excepting minor traffic violations?

YES

NO

B) Are you presently subject to a charge or indictment?

  

C) Have you personally, or has any business of which you are or were an officer, director or partner, ever been subject to bankruptcy proceedings?

 

 

D) Are there any pending legal proceedings against you or against any business of which you are an officer, director or partner?

 

 

E) Has any judgment, which is unsatisfied, ever been rendered against you personally or against any

business of which you were at the time an officer, director or partner, in any civil court in British

Columbia, or elsewhere, for any reason whatsoever?

F) Have you changed any other registration information from that previously submitted?

  

AMENDMENTS TO INFORMATION - CORPORATE, PARTNERSHIP APPLICATION

  

Since the date of the last application, has the applicant:

YES

NO

A) Been subject to proceedings in bankruptcy?

  

B) Had a judgement of a court rendered against them in any civil court in British Columbia or elsewhere, for any reason whatsoever, which is unsatisfied?

 

 

C) Been subject to any legal proceedings which are now pending?

  

D) Had any changes in officers, directors or partners?

  

E) Changed any other registration information from that previously submitted?

  

IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, ATTACH AN EXHIBIT GIVING DETAILS

APPLICANT'S SIGNATURE

DATE

 

CERTIFICATE OF APPROVAL BY INTENDED EMPLOYER (SIGNATURE OF EMPLOYER)

PRINT NAME

DATE

SIGNING AUTHORITY (SEE REVERSE FOR INSTRUCTIONS)

PRINT NAME

DATE

THIS FORM MUST BE COMPLETED AND RETURNED TO THE ABOVE ADDRESS WITH THE REQUIRED FEE, 30 DAYS PRIOR TO DUE DATE. RETAIN A COPY FOR YOUR RECORDS.

WARNING
ANY APPLICATION CONTAINING A
FALSE STATEMENT MAY RESULT IN
REFUSAL, SUSPENSION OR
CANCELLATION OF ANY REGISTRATION

SUBMIT THIS COPY

FIN 2005 Rev. 97 / 9 / 16 and Rev. 2001 / 3 / 28

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 this information can be directed to the Registration Supervisor, Registration and Market Regulation Branch, Capital Markets Regulation Division, PO Box 10142, Pacific Centre, 701 West Georgia Street, Vancouver, British Columbia V7Y 1L2. Telephone (604) 899-6692. Toll Free within British Columbia 1-800-373-6373.

IF RENEWAL REQUESTED

Check () appropriate box, complete all shaded areas, sign and return this form with required fee to the Issuing Office 30 days prior to due date. This form must also be completed by intended employer if applicable. (See below CERTIFICATE OF APPROVAL BY INTENDED EMPLOYER.)

IF RENEWAL NOT REQUIRED

Check () appropriate box, sign and return this form to the return address.

On termination of registration of an adviser, a broker, a dealer or investment dealer under the Securities Act, submit the following:

  1. Termination letter giving date of cessation of business.
  2. Written auditor's confirmation to the effect that all financial obligations under the applicable Act have been discharged and that all trust funds/client accounts have been properly disbursed.

CERTIFICATE OF APPROVAL BY INTENDED EMPLOYER to be completed as follows:

Securities Act

All salesman categories must be endorsed by employer noted in item on the front of this form.

Note: All exhibits must be duly initialed.