33-109F2 - Change or Surrender of Individual Categories [Proposed 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). 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.
Name of individual:
NRD number of individual:
- Individual categories
Indicate the individual categories that the individual is adding or removing:
- Details of surrender
If the individual is surrendering his or her registration include details regarding any:
• unresolved client complaints:
• internal discipline matters:
• restrictions for violation of regulatory requirements that occurred at any time during individual’s employment with the firm:
• 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.
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 nongovernmental 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 set out below.
(In the final draft of the form a list of contact information will be included here.)
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 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.
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 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.
Signature of registered or non-registered individual Date
Name of firm: _______________________________
Authorized signature: _______________________________
Print name: _______________________________