33-109F5 - Change of Registration Information [F - Rescinded]

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 NI 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