33-109F2 - Change or Surrender of Individual Categories [F - Lapsed]
CHANGE OR SURRENDER OF INDIVIDUAL CATEGORIES
Enter the following information using the online version of this submission at the NRD web site (www.nrd.ca). 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.
Name of individual:
NRD number of individual:
Indicate the individual categories that the individual is adding or removing:
3. Details of surrender
If the individual is surrendering his or her registration include details regarding any:
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 and Labrador, 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.
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 provided in Schedule “A”.
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.
The following certification is to be used when submitting this form in NRD format:
I am making this submission as agent for the NRD filerI am making this submission as agent for the individual to whom this submission relates. By checking this box I certify that all statements of fact in this submission were provided to me by the individual.
Both of the following certifications are to be used when submitting this form in paper format:
Certification by Individual
I, the undersigned, certify that I have read and that I understand the questions in this form and the Warning set out above.
I also certify that all statements of fact provided in this application are true.
Signature of applicant or non-registered individual Date
I, the undersigned, certify on behalf of the sponsoring firm that the individual will be engaged by the sponsoring firm as a registered individual or a non-registered individual. I certify that I have, or a branch manager or another officer or partner has, discussed the questions set out in this form and I am satisfied that the individual fully understands the questions.
Signature of authorized officer or partner Date
Notice and collection and use of personal information
Alberta Securities Commission,
British Columbia Securities Commission
The Manitoba Securities Commission
Securities Administration Branch
Newfoundland and Labrador
Securities Commission of Newfoundland and Labrador
Nova Scotia Securities Commission
Government of the Northwest Territories
Legal Registries Division
Ontario Securities Commission
Prince Edward Island
Commission des valeurs mobilières du Québec
Saskatchewan Securities Commission
Department of Community Services Yukon