31-906F - Application for Transfer/Change of Status [F - Rescinded]

APPLICATION FOR TRANSFER /
CHANGE OF STATUS
BC FORM 31-906F
(Previously Form 7A)

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, 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.

APPLICANT NAME

APPLICANT'S RESIDENTIAL ADDRESS                                                                     POSTAL CODE

EMPLOYER NAME

ADDRESS WHERE APPLICANT WILL BE WORKING                                               POSTAL CODE

ADDRESS FOR SERVICE IN THE PROVINCE                                                             POSTAL CODE

APPLYING FOR REGISTRATION AS                                                                            TYPE OF REGISTRATION

A. TRANSFER                                                                                                                   DATE OF TERMINATION
NAME OF PREVIOUS EMPLOYER                                                                                 YY / MM / DD

B. CHANGE OF STATUS
CURRENT REGISTRATION

1. APPLICABLE EXAMINATION WRITTEN - Attach proof of passing                DATE PASSED
                                                                                                                                          YY / MM / DD

2. APPLICABLE EXAMINATION WRITTEN - Attach proof of passing                 DATE PASSED
                                                                                                                                           YY / MM / DD

3. APPLICABLE EXAMINATION WRITTEN - Attach proof of passing                  DATE PASSED
                                                                                                                                            YY / MM / DD

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. If yes, attach full particulars.                                                        PLEASE ( ) ONE
                                                                                                                                                     YES      NO

CERTIFICATION - 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 or Securities Rules.

APPLICANT SIGNATURE                                                     PRINT APPLICANT'S NAME                              DATE SIGNED
                                                                                                                                                                                 YY / MM / DD

SIGNATURE OF PARTNER, DIRECTOR OR OFFICER                                                                                      PRINT NAME OF PARTNER, DIRECTOR OR
                                                                                                                                                                                OFFICER OF THE DEALER, ADVISER OR
                                                                                                                                                                                UNDERWRITER THAT EMPLOYS THE APPLICANT

                                                                                                                                                                                 DATE SIGNED
                                                                                                                                                                                 YY / MM / DD

FIN 31-906F Rev. 2001/3/15

NOTE: The following areas are addressed in the Uniform Application and constitute questions 11 through 20 respectively:

CHANGE OF NAME

PRIOR REGISTRATION OR LICENSING

REFUSAL, SUSPENSION, CANCELLATION OR DISCIPLINARY MEASURE

SELF - REGULATORY ORGANIZATIONS

OFFENCES UNDER THE LAW

CIVIL PROCEEDINGS

BANKRUPTCY

JUDGMENT OR GARNISHMENT

SURETY BOND OR FIDELITY BOND