Securities Law

33-109F3 - Business Locations Other Than Head Office [Proposed F - Lapsed]

Published Date: 2001-12-14

FORM 33-109F3

BUSINESS LOCATIONS OTHER THAN HEAD OFFICE

NRD SUBMISSION

A Form 33-109F3 submission in NRD format shall contain the information prescribed below. The information shall be entered using the online version of this submission accessible by a firm filer at the NRD web site (www.nrd.ca).

TEMPORARY HARDSHIP EXEMPTION

This form is required to be delivered to the regulator if a firm filer is relying on the temporary hardship exemption in MI 31-102. Indicate, where applicable, any changes 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. Type of business location

    ___________ branch

    ___________ sub-branch

    ___________ chief place of business

  2. Supervisor or branch manager

    NRD number of the designated supervisor or branch manager:

    Name of designated supervisor or branch manager:

  3. Business location information

    Business address:

    Telephone number: (    )

    Facsimile number: (     )

    Mailing address (if different from business address):

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.

The principal purpose for which this collection of personal information is to be used is to assess your suitability for registration, if applicable, and to assess your continued fitness for registration 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 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.

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 my by the firm for who this submission is being made and that this submission is being made at the request of the firm.

Dated this ______________________ day of ________________, 200_________.

Name of firm: ____________________________________

Authorized signature: ____________________________________

Print name: ____________________________________

Title: ____________________________________