Unofficial Consolidation: Form 33-109F5 Change of Registration Information

Unofficial Consolidation: Form 33-109F5 Change of Registration Information

Unofficial Consolidation Forms

Ontario Securities Commission

FORM 33-109F5
CHANGE OF REGISTRATION INFORMATION

Unofficial consolidation current to 2022-06-06.

This document is not an official statement of law or policy and should be used for reference purposes only.

FORM 33-109F5
CHANGE OF REGISTRATION INFORMATION
(sections 3.1 and 4.1)

WARNING - It is an offence to knowingly give false or misleading information to the regulator or the securities regulatory authority.

CERTIFICATION

1. Form 33-109F4: Use the following certification when making changes to Form 33-109F4

Individual

I, the individual, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where I am submitting this form and to any applicable self-regulatory organization (SRO) that

  • I have read this form,
  • I have read Form 33-109F4 and understand its questions and, for greater certainty, if the business location is a residence, the notice in Item 9,
  • I have discussed Form 33-109F4 with a branch manager, supervisor, officer or partner of my sponsoring firm and that to the best of my knowledge, the branch manager, supervisor, officer or partner is satisfied that I understand all matters within Form 33-109F4, including the questions,
  • to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete, including information required to be disclosed by Form 33-109F4 that I am not changing with this form, and
  • if applicable, I will limit my activities to those allowed by my category of registration and any SRO approval.

I consent to and authorize the collection, directly and indirectly, of personal information by each regulator, securities regulatory authority and SRO and to the use of my personal information as set out in Item 3.

Firm

I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm is submitting this form and to any applicable SRO that

  • the individual identified in this form will be engaged by the sponsoring firm as a registered individual or a permitted individual, and
  • I have, or a branch manager, supervisor, officer or partner has, discussed Form 33-109F4 with the individual. To the best of my knowledge, the individual understands all matters within Form 33-109F4, including the questions.

NRD format:

  I, the authorized firm representative, am making this submission under authority delegated by the firm and the individual identified in this form. By checking this box, I certify that

  1. the firm provided me with all of the information on this form and makes the firm certification above,
  2. the individual provided the firm with all of the information on this form and makes the individual certification above, and
  3. the individual provided the above consent and authorization for the collection and use of the individual’s personal information.

Non-NRD format:

Individual

By signing below, I, the individual, make the above individual certification and provide my consent and authorization for the collection, directly and indirectly, and use of my personal information.

Signature of individual__________________________

Date signed _________________
(YYYY/MM/DD)

Firm

▢ By signing below, I, on behalf of the firm, make the firm certification above.

Name of firm _________________________________________

Name of authorized signing officer or partner _________________________________________

Title of authorized signing officer or partner _________________________________________

Signature of authorized signing officer or partner_________________________________________

Date signed ______________________
(YYYY/MM/DD)

2. Form 33-109F6: Use the following certification when making changes to Form 33- 109F6

By signing below, I, on behalf of the firm, certify to the regulator or, in Québec, the securities regulatory authority in each jurisdiction where the firm submitting this form and to any applicable SRO that

  • I have read this form and understand all matters within this form, including the questions, and to the best of my knowledge and after reasonable inquiry, all of the information provided on this form is true and complete.

Name of firm _________________________________________

Name of authorized signing officer or partner _________________________________________

Title of authorized signing officer or partner _________________________________________

Signature of authorized signing officer or partner_________________________________________

Date signed ______________________
(YYYY/MM/DD)

GENERAL INSTRUCTIONS

Complete and submit this form to notify the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-regulatory organization (SRO) of changes to information in the following forms:

  • Form 33-109F6, except for the changes set out in section 3.1 of National Instrument 33-109, or
  • Form 33-109F4.

How to submit this form

To report changes to information in a Form 33-109F4, submit this form at the National Registration Database website in NRD format at www.nrd.ca.

Submit this form in a format other than NRD format to report changes to information in a:

  1. Form 33-109F6, or
  2. Form 33-109F4, if the individual is relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database.

Name of firm ___________________________________________________________________________

Registration categories ___________________________________________________________________________

NRD number (firm) ___________________________________

Item 1             Type of form

Check the form that is being updated:

▢ Form 33-109F6

If submitting changes to Form 33-109F6, please attach a blackline of the amended sections of the form.

▢ Form 33-109F4     Name of individual                              ________________________________

Item 2             Details of change

Provide the item number and details for each change to the form selected above:

Item number______    Details _______________________

Effective date of change ___________________________
(YYYY/MM/DD)

Item 3 Notice and consent for collection and use of personal information

1.         Notice of collection and use of personal information

Your personal information is collected by, or on behalf of, each securities regulatory authority and SRO set out in Schedule A. Any of the securities regulatory authorities, or SROs set out in Schedule A may contact governmental or regulatory authorities, private bodies or agencies, individuals, corporations, employers, and other organizations, in Canada and in other countries, for information about you.

This personal information is being collected under the authority of the applicable securities legislation, derivatives legislation (including commodity futures legislation) or both of the securities regulatory authorities and under the SRO rules of an SRO set out in Schedule A. The collection, use and disclosure are done in accordance with applicable freedom of information and privacy legislation.

The principal purpose of this collection by the securities regulatory authorities is to administer, enforce, carry out their duties or exercise their powers under their respective securities legislation, derivatives legislation (including commodity futures legislation) or both, and by the SROs to administer and enforce the rules of the SROs.

The information submitted by you in this form with your consent, or collected indirectly with your authorization, may be collected

  • at any time during your registration or while you are a permitted individual, or
  • at the time the regulator or, in Québec, the securities regulatory authority, or the SRO is informed by your sponsoring firm that you no longer have authority to act on behalf of the sponsoring firm or are not a permitted individual of the sponsoring firm.

If you have any questions about the collection, use and disclosure of this information, contact the securities regulatory authority or SRO in any jurisdiction in which the required information is submitted. See Schedule A for details.

Certain information, such as your name(s) (including aliases, trade names or some past names), your sponsoring firm, and other relevant registration information, will be listed in a publicly available registry of registered individuals and, if applicable, on the Disciplined List.

Certain securities regulatory authorities may provide to or receive from certain entities information under separate provisions of their securities legislation or derivatives legislation (including commodity futures legislation) or both, and SROs may provide or receive information under the rules of the SROs.  This consent and notice does not limit the authority, powers, obligations or rights conferred on any of the securities regulatory authorities by legislation or regulations in effect in their jurisdiction.

2.         Consent to collect and use personal information

By submitting this form, you consent to and authorize the collection, directly and indirectly, of personal information by each securities regulatory authority and SRO and to the use of your personal information as set out above.

The personal information that each securities regulatory authority or SRO collects includes the following:

  • the personal information provided in this form;
  • the personal information provided by your sponsoring firm;
  • registration or financial services licensing information;
  • law enforcement records, including police records;
  • credit records;
  • bankruptcy or other insolvency records;
  • employment records and information received from an employer; 
  • records and information received from entities you had or have an independent contractor or agency relationship with;
  • personal information available online;
  • records from governmental or regulatory authorities, SROs or professional bodies;
  • records of, and used in, court proceedings, including probation records.

Item 4             [repealed]

Item 5             [repealed]

 

Schedule A
Contact information for
notice and consent for collection and use of personal information
 

 

Alberta
Alberta Securities Commission,
Suite 600, 250–5th St. SW
Calgary, AB T2P 0R4
Attention: Information Officer
Telephone: (403) 297-6454

Nunavut
Government of Nunavut
Department of Justice
P.O. Box 1000 Station 570
Iqaluit, NU X0A 0H0
Attention: Deputy Registrar of Securities
Telephone: (867) 975-6590

British Columbia
British Columbia Securities Commission
P.O. Box 10142, Pacific Centre
701 West Georgia Street
Vancouver, BC V7Y 1L2
Attention: Registration staff
Telephone: (604) 899-6500 or (800) 373-6393 (in Canada)
E-mail: [email protected]

Ontario
Ontario Securities Commission
22nd Floor
20 Queen Street West
Toronto, ON M5H 3S8
Attention: Compliance and Registrant Regulation
Telephone: (416) 593-8314
E-mail: [email protected]

Manitoba
The Manitoba Securities Commission
500 - 400 St. Mary Avenue
Winnipeg, MB R3C 4K5
Attention: Director of Registrations
Telephone: (204) 945-2548
Fax (204) 945-0330

Prince Edward Island
Securities Office
Department of Community Affairs and Attorney
P.O. Box 2000
Charlottetown, PE C1A 7N8
Attention: Deputy Registrar of Securities
Telephone: (902) 368-6288

New Brunswick
Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick
Suite 300, 85 Charlotte Street
Saint John, NB  E2L 2J2
Attention:  Director of Securities
Telephone: (506) 658-3060

Québec
Autorité des marchés financiers
800, square Victoria, 22e étage
C.P. 246, tour de la Bourse
Montréal (Québec) H4Z 1G3
Attention: Responsable de l’accès à l’information
Telephone: (514) 395-0337 or (877) 525-0337

Newfoundland and Labrador
Superintendent of Securities, Service NL
Government of Newfoundland and Labrador
P.O. Box 8700
2nd Floor, West Block
Confederation Building
St. John's, NL A1B 4J6
Attention: Manager of Registrations
Telephone: (709) 729-5661

Saskatchewan
Financial and Consumer Affairs Authority of Saskatchewan
Suite 601, 1919 Saskatchewan Drive
Regina, SK S4P 4H2
Attention: Director, Capital Markets
Telephone: (306) 787-5871
Email: [email protected]

Nova Scotia
Nova Scotia Securities Commission
Suite 400, 5251 Duke Street
Halifax, NS B3J 1P3
Attention: Registration
Telephone: (902) 424-7768

Yukon
Government of Yukon
Office of the Yukon Superintendent of Securities
Department of Community Services
P.O. Box 2703 C-6
Whitehorse, YT Y1A 2C6
Attention: Superintendent of Securities
Telephone: (867) 667-5466

Northwest Territories
Government of the Northwest Territories
Department of Justice
1st Floor Stuart M. Hodgson Building
5009 – 49th Street
Yellowknife, NWT X1A 2L9
Attention: Superintendent of Securities
Telephone: (867) 920-8984

Self-regulatory organization
Investment Industry Regulatory Organization of Canada
121 King Street West, Suite 2000
Toronto, Ontario M5H 3T9
Attention: Privacy Officer
Telephone: (416) 364-6133
E-mail: [email protected]