33-109F5 - Change of Registration Information [Proposed F - Lapsed]
| Published Date: | 2002-06-14 |
|---|
FORM 33-109F5
CHANGE OF REGISTRATION INFORMATION
GENERAL INSTRUCTIONS
- This notice must be submitted when notifying a regulator of changes to Form 3 or Form 4 information in accordance with MI 33-109.
- 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.
- 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.
- 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 ____________________ - 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, 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 nongovernmental 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 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
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.
Name of firm: _______________________________
Authorized signature: _______________________________
Print name: _______________________________
Title: _______________________________
Date: _______________________________