Securities Law

33-109F5 - Change of Registration Information [F - Rescinded]

Published Date: 2007-05-15
Rescinded Date: 2009-09-28
Document(s):

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

SCHEDULE “A”

Notice and collection and use of personal information

Contact Information

 

Alberta

 

AlbertaSecurities Commission,

4th Floor, 300 B 5th Avenue S.W.

Calgary, AB   T2P 3C4

Attention:  Information Officer

Telephone: (403) 297-6454             

British Columbia

 

British ColumbiaSecurities Commission

P.O. Box10142, 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 Box5001

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. Box8700, 2nd Floor, West Block

ConfederationBuilding

St. John's, NF   A1B 4J6

Attention:  Director of Securities

Tel: (709) 729-4189

 

Nova Scotia

 

Nova ScotiaSecurities Commission

2nd Floor, Joseph Howe Building

1690 Hollis Street

P.O. Box458

Halifax, NS   B3J 3J9

Attention:  FOI Officer

Telephone:  (902) 424-7768

Northwest Territories

 

Government of the Northwest Territories

P.O. Box1320

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. Box1000Station 570

Iqaluit, NU X0A 0H0

Attention:  Deputy Registrar of Securities

Telephone: (867) 975-6190

Ontario

 

OntarioSecurities Commission

Suite1903, 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. Box2000

Charlottetown, PE C1A 7N8

Attention:  Deputy Registrar of Securities

Telephone:  (902) 368-4569            

Québec

 

Commission des valeurs mobilières du Québec

StockExchange Tower

P.O. Box246, 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

 

SaskatchewanSecurities Commission

800 B1920 Broad Street

Regina, SK   S4P 3V7

Attention:  Director

Telephone:  (306) 787-5842

 

Yukon

 

Department of Community Services Yukon

P.O. Box2703

Whitehorse, YU Y1A 2C6

Attention:  Registrar of Securities

Telephone:  (867) 667-5225