33-109F1 - Notice of Termination [Proposed F - Lapsed]

FORM 33-109F1

NOTICE OF TERMINATION

Enter the following information using the online version of this submission at the NRD web site

(www.nrd.ca). However, if the NRD filer is relying on the temporary hardship exemption in MI 31-102, this form is required to be delivered to the regulator in paper format.

1. Individual
   
   Name of individual: ____________________________________
   
   NRD number of individual: ______________________________
   
   
2. Business location
   
   Name of firm: _______________________________________
   
   Address of relevant business location: ____________________________________________
   
   NRD number of relevant business location: _______________________________________________
   
   
3. Individual categories
   
   Indicate the registration or non-registered category of the individual as of the last date of employment:
   
   
   
4. Termination
   
   Effective date of termination:
   
   Indicate whether the individual:
   
   • was dismissed for cause
   • was dismissed in good standing
   • resigned in good standing
   • is deceased.
   
   Include details regarding any:
   
   • unresolved client complaints:
   
   
   • internal discipline matters:
   
   
   • restrictions for violation of regulatory requirements:
   
   
   • financial obligations the individual has to clients:
   

Notice of Collection and Use of Personal Information

The personal information required under this form is collected on behalf of and used by the securities regulatory authorities set out below for the administration and enforcement of certain provisions of the securities legislation in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, New Brunswick, Prince Edward Island, Newfoundland, Northwest Territories, Yukon Territory and Nunavut.

If you have any questions about the collection and use of this information, you may contact the securities regulatory authority in any jurisdiction in which the required information is filed, at the address or telephone number set out below.

(In the final draft of the form a list of contact information will be included here.)

WARNING:

It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue.

CERTIFICATION

The following certification is to be used when submitting this form in NRD format:

• I am making this submission as agent for the NRD filer. By checking this box I certify that all statements of fact in this submission were provided to me by the NRD filer and that this submission is being made at the request of the NRD filer.
  
  OR

The following certification is to be used when submitting this form in paper format:

I, the undersigned, certify that I have read and that I understand the questions in the notice and the Warning set out above. I also certify that all statements of fact made in the answers to the questions are true.

Dated this ______ day of ____________ , 20___ .

Name of firm: ________________________________

Authorized signature: _______________________________

Print name: _________________________________

Title: ______________________________________