33-109F2 - Change of Individual Categories [Proposed F - Lapsed]

FORM 33-109F2

CHANGE OF INDIVIDUAL CATEGORIES

NRD SUBMISSION

A Form 33-109F2 submission in NRD format shall contain the information prescribed below. The information shall be entered using the online version of this submission accessible by an NRD filer at the NRD web site (www.nrd.ca).

TEMPORARY HARDSHIP EXEMPTION

This form is required to be delivered to the regulator if an NRD filer is relying on the temporary hardship exemption in MI 31-102. Indicate, where applicable, the change to information previously submitted to the regulator. In addition, all applicable questions must be answered and must be legible. All attachments pertaining to any question must be made exhibits to the form and each one must be so marked. All signatures must be original.

1. Individual
   
   Name of individual:
   
   NRD number of individual:
   
   
2. Individual categories
   
   Indicate the individual categories that the individual is adding or removing:
   
   OR:
   
   Indicate the individual categories that the individual is applying to surrender and complete section 3 below:
   
   
3. Details of surrender
   
   Include any details regarding all:
   
   • unresolved client complaints:
   • internal discipline matters:
   • restrictions for violation of regulatory requirements that occurred at any time during individual’s
   employment with the firm:
   
   Indicate whether the individual has discharged all of his or her financial obligations to their 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 purposes of 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.

By submitting this information you consent to the collection by the securities regulatory authority of the personal information provided above, police records, records from other government or non-governmental regulatory authorities or self-regulatory organizations, credit records and employment records about you as may be necessary for the securities regulatory authority to complete its review of the information submitted above including your continued fitness for registration, if applicable, in accordance with the legal authority of the securities regulatory authority for the duration of the period which you remain registered or approved by the securities regulatory authority. The sources the securities regulatory authority may contact include government and private bodies or agencies, individuals, corporations and other organizations.

The principal purpose for which this collection of personal information is to be used is to assess your continued fitness for registration, if applicable, in accordance with the applicable securities legislation.

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 paper format:

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

OR

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

Q I certify that all statements of fact in this submission were provided to me by the NRD filer for whom this submission is being made and that this submission is being made at the request of the NRD filer.

Dated this _____________ day of _______________________________, 200____ .

Name of individual: ____________________________________________

Signature of individual: __________________________________________

OR

Name of firm (if applicable): ____________________________________

Authorized signature: ________________________________________

Print name: ________________________________________

Title: ________________________________________