33-109F3 - Business Locations other than Head Office [Proposed F - Lapsed]

FORM 33-109F3

BUSINESS LOCATIONS OTHER THAN HEAD OFFICE

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.

Please select one box:

• This form is being submitted to notify the regulator of the opening of this business location.  Complete the entire form.
• This form is being submitted to notify the regulator of the closing of this business location. Complete the entire form.
• This form is being submitted to notify the regulator the change of information previously submitted in respect of this business location. Complete the entire form and describe the information that has changed (for example, “telephone number” or “type of business location”): ____________________________

1. Type of business location
   
   ____ branch
   
   ____ sub-branch
   
   
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 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 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.

Name of firm: _______________________________

Authorized signature: _______________________________

Print name: _______________________________

Title: _______________________________

Date: _______________________________