Securities Law

33-109F5 - Change of Registration Information [F - Lapsed]

Published Date: 2003-02-07
Effective Date: 2003-02-21

FORM 33-109F5

CHANGE OF REGISTRATION INFORMATION

GENERAL INSTRUCTIONS

1. This notice must be submitted when notifying a regulator of changes to Form 3 or Form 4 information in accordance with MI 33-109.

2. 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 when notifying a regulator of changes to Form 33-109F4.

3. If this form is being submitting in respect of a change to a Form 3, Form 4 or Form 33-109F4 an authorized partner or officer of the firm must sign the form.

1. Type of form

Identify the part of the Form 3, Form 4, or Form 33-109F4 for which this notice is being provided. If this notice is being provided to update an individual’s Form 4 or Form 33-109F4, provide the name of the individual.

Form 3, Item(s) ________________________________,
 
Form 4, Item(s) __________________________________, name of individual ______________________________, or
 
Form 33-109F4, Item(s) ______________________________________, name of individual ___________________________________



2. Details of Change

Provide the details of the change for each item identified above:






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 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”.


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

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
(No signature is required here if this form is being submitted in respect of a change to Form 3 information.)

If this form is being submitted in respect of a change to Form 3, I, the undersigned, certify that I understand the requirements and the Warning in this notice and that all statements of fact provided in this notice are true.


_                                                                                                           
Signature of authorized officer or partner Date


________________________________________________
Firm name





SCHEDULE “A”
Notice and collection and use of personal information

Contact Information

 

Alberta

Alberta Securities Commission,
4th Floor, 300 B 5th Avenue S.W.
Calgary, AB T2P 3C4
Attention: Information Officer
Telephone: (403) 297-6454

British Columbia

British Columbia Securities Commission
P.O. Box 10142, Pacific Centre
701 West Georgia Street
Vancouver, BC V7Y 1L2
Attention: Freedom of Information Officer
Telephone: (604) 899-6500 or (800) 373-6393 (in BC)

 

Manitoba

The Manitoba Securities Commission
1130-405 Broadway
Winnipeg, MB R3C 3L6
Attention: Director - Legal
Telephone: (204) 945-4508

New Brunswick

Securities Administration Branch
PO Box 5001
606, 133 Prince William Street
Saint John, NB E2L 4Y9
Attention: Deputy Administrator, Capital Markets
Telephone: (506) 658-3021

 

Newfoundland and Labrador

Securities Commission of Newfoundland and Labrador
P.O. Box 8700, 2nd Floor, West Block
Confederation Building
St. John's, NF A1B 4J6
Attention: Director of Securities
Tel: (709) 729-4189

Nova Scotia

Nova Scotia Securities Commission
2nd Floor, Joseph Howe Building
1690 Hollis Street
P.O. Box 458
Halifax, NS B3J 3J9
Attention: FOI Officer
Telephone: (902) 424-7768

 

Northwest Territories

Government of the Northwest Territories
P.O. Box 1320
Yellowknife, NWT X1A 2L9
Attention: Deputy Registrar of Securities
Telephone: (867) 920-8984

Nunavut

Legal Registries Division
Department of Justice
Government of Nunavut
P.O. Box 1000 Station 570
Iqaluit, NU X0A 0H0
Attention: Deputy Registrar of Securities
Telephone: (867) 975-6190

 

Ontario

Ontario Securities Commission
Suite 1903, Box 55
20 Queen Street West
Toronto, ON M5H 3S8
Attention: FOI Coordinator
Telephone: (416) 593-8314

Prince Edward Island

Securities Registry
Office of the Attorney General B Consumer, Corporate and Insurance Services Division
P.O. Box 2000
Charlottetown, PE C1A 7N8
Attention: Deputy Registrar of Securities
Telephone: (902) 368-4569

 

Québec

Commission des valeurs mobilières du Québec
Stock Exchange Tower
P.O. Box 246, 22nd Floor
800 Victoria Square
Montréal, PQ H4Z 1G3
Attention: Responsable de l’accès à l’information
Telephone: (514) 940-2150 or
(800) 361-5072 (in Québec)

Saskatchewan

Saskatchewan Securities Commission
800 B1920 Broad Street
Regina, SK S4P 3V7
Attention: Director
Telephone: (306) 787-5842

 

Yukon

Department of Community Services Yukon
P.O. Box 2703
Whitehorse, YU Y1A 2C6
Attention: Registrar of Securities
Telephone: (867) 667-5225