FORM 33-109F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL

SUBMISSION TO NRD

Enter the following information using the online version of this submission at the NRD web site (www.nrd.ca). 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.

INSTRUCTIONS FOR FILING IN PAPER FORMAT

1. This form is to be used by every individual seeking registration from a securities regulatory authority or a self-regulatory
organization or who is a non-registered individual with a registered firm or a firm seeking registration.

2. This form is also to be used by any sole proprietor submitting an application for registration as a dealer, broker, adviser
or underwriter to a securities regulatory authority.

3. Failure to answer all applicable questions may cause delays in the processing of the application form.

4. This form must be legible.

5. To complete the application, individuals should seek advice from an authorized officer of the sponsoring firm or from a
legal adviser.

6. The number of originally signed copies of the form to be filed with the self-regulatory organization and/or securities
regulatory authority or similar authority varies from province to province. If unsure of the procedure, please consult the
Registration Department of the self-regulatory organization to which you are applying or the applicable securities
regulatory authority, or similar authority.
Item 1 – Name

1. Legal name

Last name First name Second name Third name

(if applicable) (if applicable)
2. Other names
Are you currently, or have you previously been, known by a name other than the name provided above?…. “ Yes “ No

If “Yes”, complete Schedule “A”.

Item 2 - Residential address

Current address
Provide all residential addresses, including any foreign residential addresses, for the past 10 years.

Current residential address:

(number, street, city, province, territory or state, country, postal code)

Telephone number: ( ) Resided at this address since: /

(YYYY/MM)

If you have resided at this address for less than 10 years, complete Schedule “B”.
 FORM 33-109F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL

Item 3 – Personal information

Personal description

Date of birth: Place of birth:

(YYYY/MM/DD) (city, province, territory or state, country)
Gender: “ Female “ Male Colour of eyes: Colour of hair:

Height: imperial units: OR metric units: cm

Weight: imperial units: lbs OR metric units: kg

Item 4 – Citizenship

Citizenship information
What is your citizenship?

“ Canadian
“ Other, specify:

If you are a citizen of a country other than Canada, complete the following for that other citizenship. You are only required
to provide the following information for one citizenship.

Passport number: Country of citizenship:

Date of issue:
(YYYY/MM/DD)

Place of issue:
(city, province, territory or state, country)
Item 5 - Registration jurisdictions

Jurisdictions
Indicate, by checking the appropriate box, each province or territory to which you are submitting this form:

‘ Alberta ‘ Northwest Territories ‘ Prince Edward Island

‘ British Columbia ‘ Nova Scotia ‘ Québec
‘ Manitoba ‘ Nunavut ‘ Saskatchewan
‘ New Brunswick ‘ Ontario ‘ Yukon Territory
‘ Newfoundland and Labrador

Item 6 - Individual categories

Categories
Indicate, by checking the appropriate box in Schedule “C”, each registration category for which you are applying. If you
are a non-registered individual and you are not applying for registration, indicate each category that describes your
position with your sponsoring firm.
 FORM 33-109F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL
Item 7 - Address and agent for service

1. Address for service

You must have one address for service in each province or territory in which you are now, or are applying to become, a
registered individual or non-registered individual. A post office box is not an acceptable address for service. Complete
Schedule “D” for each additional address for service you are providing.

Address for service:

(number, street, city, province or territory, postal code)

Telephone number: ( ) Fax number: ( )

E-mail address:

2. Agent for service

If you have appointed an agent for service, provide the following information for the agent. The address for service
provided above must be the address of any agent named below.

Name of agent for service:

Contact person:
Last name First name
Item 8 – Proficiency

1. Course or examination information

Complete Schedule “E” to indicate each course and examination that you have successfully completed or for which you
have received an exemption.

If you are not required under securities legislation or the rules of a self-regulatory organization to satisfy any course
or examination requirements you are not required to complete this item.
2. Student numbers
If you have a student number with one of the following institutions, provide it below:

Canadian Securities Institute (CSI):

Investment Funds Institute of Canada (IFIC):

Institute of Canadian Bankers (ICB):

Association for Investment Management and Research (AIMR):

Canadian Association of Insurance and Financial Advisors (CAIFA):

3. Exemption refusal
Has any securities regulatory authority or self-regulatory organization refused to grant you an exemption from a course,
examination or experience requirement? ..............................................................………………………........... “ Yes “ No

If “Yes”, complete Schedule “F”.

 FORM 33-109F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL
Item 9 – Location of employment

Location of employment
Provide the following information for the location of the sponsoring firm at which you will be working. If you will be working
out of more than one location, provide the following information for the location out of which you will be doing most of your
business.

NRD number:

Business address:
(number, street, city, province, territory or state, country, postal code)

Telephone number: ( ) Fax number: ( )

“ Check here if the mailing address of the location is the same as the business address provided above. Otherwise,
complete the following:

Mailing address:
(number, street, city, province, territory or state, country, postal code)
Item 10 - Current employment

Employment information
On Schedule “G”, provide the information requested for your current business and employment activities, including those
with your sponsoring firm.

“ Check here if you are not required under securities legislation to provide this information.
Item 11 - Previous employment

Employment information
On Schedule “H”, provide the information requested for your previous business and employment activities for the 10-year
period before the date of this application. Include any periods of self-employment or unemployment during this period. Do
not include summer employment while you were a full-time student.

In addition, provide the information requested for all of your securities or exchange contracts (including commodity futures
contracts and commodity futures options) business and employment activities during and prior to the ten-year period.

“ Check here if you are not required under securities legislation to provide this information.

“ Check here if the information required by this section has been provided in Item 10.
Item 12 - Resignations and terminations

Resignation and termination information

Have you ever resigned or been terminated following allegations, made by a client, sponsoring firm, self-regulatory
organization, securities regulatory authority or any other regulatory authority that you:

a) violated investment related statutes, regulations, rules or industry standards of conduct? ……………..... “ Yes “ No

b) failed to supervise in connection with investment related statutes, regulations, rules or industry standards
of conduct? .........................................................................................................................…………….... “ Yes “ No

c) committed fraud or the wrongful taking of property? ........................................................……………...... “ Yes “ No

If “Yes”, to any of the above questions, complete Schedule “I”.

 FORM 33-109F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL
Item 13 – Regulatory disclosure

1. Securities regulatory authorities

a) Other than a registration that has been recorded on NRD under the NRD number you are using to make this
submission, are you now, or have you ever been, registered or licensed to trade in or advise on securities or
exchange contracts (including commodity futures contracts and commodity futures options) in any province,
territory, state or country? ..................................…………………………………………………….......…. “ Yes “ No

If “Yes”, complete Schedule “J”, section 1(a).

b) Are you now, or have you ever been, a partner, director, officer, or holder of voting securities carrying more than 10
percent of the votes carried by all outstanding voting securities of any firm which has been registered or licensed, or
is now registered or licensed, to trade in or advise on securities or exchange contracts (including commodity futures
contracts and commodity futures options) in any province, territory, state or country? ........................... “ Yes “ No

If “Yes”, complete Schedule “J”, section 1(b).

c) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been
refused registration or a license to trade in or advise on securities or exchange contracts (including commodity
futures contracts and commodity futures options) in any province, territory, state or country?................... “Yes “ No

“Yes”, complete Schedule “J”, section 1(c).

d) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been
denied the benefit of any exemption from registration provided by securities legislation or legislation governing
exchange contracts (including commodity futures contracts and commodity futures options) in any province,
territory, state or country? .............................................................................................................................. “ Yes “ No

If “Yes”, complete Schedule “J”, section 1(d).

e) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been
subject to a cease trade order, a cease distribution order, a suspension or termination order, any disciplinary
proceedings or any order resulting from disciplinary proceedings pursuant to securities legislation or legislation
governing exchange contracts (including commodity futures contracts and commodity futures options) in any
province, territory, state or country? ............................................................................................................. “ Yes “ No

If “Yes”, complete Schedule “J”, section 1(e).

2. Self-regulatory organizations
a) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been a
member or participating organization of any stock exchange or other self-regulatory organization in any province,
territory, state or country?.............................................................................................................................. “ Yes “ No

If “Yes”, complete Schedule “J”, section 2(a).

b) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been
refused membership or entry as a participating organization in any stock exchange or other self-regulatory
organization in any province, territory, state or country? ............................................................................. “ Yes “ No

If “Yes”, complete Schedule “J”, section 2(b).

c) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been
subject to a suspension, expulsion or termination order, or been subject to any disciplinary proceedings or any order
resulting from disciplinary proceedings conducted by any stock exchange or other self-regulatory organization in
any province, territory, state or country? ...................................................................................................... “ Yes “ No

If “Yes”, complete Schedule “J”, section 2(c).

 FORM 33-109F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL
3. Non-securities regulation
a) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been
registered or licensed under any legislation which requires registration or licensing to deal with the public in any
capacity other than to trade in or advise on securities or exchange contracts (including commodity futures contracts
and commodity futures options) in any province, territory, state or country? .......................................... “ Yes “ No

If “Yes”, complete Schedule “J”, section 3(a).

b) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been
refused registration or a licence under any legislation which requires registration or licensing to deal with the public
in any capacity other than to trade in or advise on securities or exchange contracts (including commodity futures
contracts and commodity futures options) in any province, territory, state or country? .............................. “ Yes “ No

If “Yes”, complete Schedule “J”, section 3(b).

c) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been
subject to a suspension or termination order, or disciplinary proceedings or any order resulting from disciplinary
proceedings conducted under any legislation which requires registration or licensing to deal with the public in any
capacity other than to trade in or advise on securities or exchange contracts (including commodity futures contracts
and commodity futures options) in any province, territory, state or country? .......................................... “ Yes “ No

If “Yes”, complete Schedule “J”, section 3(c).

Item 14 - Criminal disclosure

Criminal, provincial and territorial offences

With respect to questions (b) and (d) below, if you or your firm have pleaded guilty or been found guilty of an offence, that
offence must be reported even if an absolute or conditional discharge has been granted with respect to the offence. You
are not required to disclose any offence for which a pardon has been granted under the Criminal Records Act (Canada)
unless the pardon has been revoked. You are not required to disclose speeding or parking violations.
a) Is there currently an outstanding charge against you alleging an offence that was committed in any province,
territory, state, or country? .......................................................................................................................... “ Yes “ No

If “Yes”, complete Schedule “K”, section (a).

b) Have you, since attaining the age of 18, ever been convicted of, pleaded guilty to or no contest to an offence that
was committed in any province, territory, state, or country? ..................................................................... “ Yes “ No

If “Yes”, complete Schedule “K”, section (b).

c) Have charges been laid, alleging an offence that was committed in any province, territory, state, or country against
any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in
response to Item 13(1)(b)) in which you are or were at the time of that event a partner, director, officer or holder of
voting securities carrying more than 10 percent of the votes carried by all outstanding voting
securities? ...................................................................................................................................................... “ Yes “ No

If “Yes”, complete Schedule “K”, section (c).

d) Has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and
identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting securities
carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been convicted of,
pleaded guilty to or no contest to an offence that was committed in any province, territory, state, or
country? ........................................................................................................................................................... “ Yes “ No

If “Yes”, complete Schedule “K”, section (d).

 FORM 33-109F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL
Item 15 - Civil disclosure

Current and past civil proceedings

a) Have you, or has any firm (other than your sponsoring firm or a firm that is or was registered in a Canadian
jurisdiction and identified in response to Item 13(1)(b)), when you were a partner, director, officer or holder of voting
securities carrying more than 10 percent of the votes carried by all outstanding voting securities of that firm, been a
defendant or respondent in any civil proceeding in which fraud, theft, deceit, misrepresentation, or similar conduct
is, or was, alleged? ........................................................................................................................................ “ Yes “ No

If “Yes”, complete Schedule “L”, section (a).

b) Other than what you disclosed in Item 15(a), were you, at the time the events that led to the civil proceeding
occurred, a partner, director or officer or a holder of securities carrying more than 10 percent of the votes of all
outstanding voting securities of a firm (other than your sponsoring firm or a firm that is or was registered in a
Canadian jurisdiction and identified in response to Item 13(1)(b)) that is or was a defendant or respondent in any civil
proceeding in which fraud, theft, deceit, misrepresentation, or similar conduct is or was alleged? ......... “ Yes “ No

If “Yes”, complete Schedule “L”, section (b).

Item 16 – Financial disclosure

1. Bankruptcy
Under the law of any province, territory, state, or country have you, or has any firm (other than your sponsoring firm or a
firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)), when you were a
partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried by all outstanding
voting securities of that firm:

a) had a petition in bankruptcy issued against you or the firm or made a voluntary assignment in bankruptcy?
........................................................................................................................................................................... “ Yes “ No

b) made a proposal under any legislation relating to bankruptcy or insolvency? ............................................. “ Yes “ No

c) been subject to proceedings under any legislation relating to the winding up, dissolution or companies’ creditors
arrangement?................................................................................................................................................... “ Yes “ No

d) been subject to or instituted any proceedings, arrangement or compromise with creditors (including having a
receiver, receiver-manager, administrator or trustee appointed by or at the request of creditors, either privately, or
through court process, or by order of a regulator, to hold your assets)? ................................................... “ Yes “ No

If “Yes” to any of the above questions, complete Schedule “M”, section 1.

2. Debt Obligations
Have you ever failed to meet a financial obligation of $500 or more as it came due, or has any firm (other than your
sponsoring firm or a firm that is or was registered in a Canadian jurisdiction and identified in response to Item 13(1)(b)),
when you were a partner, director, officer or holder of voting securities carrying more than 10 percent of the votes carried
by all outstanding voting securities of that firm, failed to meet a financial obligation as it came due? .............. “ Yes “ No

If “Yes”, complete Schedule “M”, section 2.

3. Surety bond or fidelity bond
Have you ever applied for a surety or fidelity bond and been refused? ...................……………….................. “ Yes “ No

If “Yes”, complete Schedule “M”, section 3.

 FORM 33-109F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL
4. Garnishments, unsatisfied judgments or directions to pay
Are there currently, or have there been, outstanding against you any of the following:

a) garnishments,

b) unsatisfied judgments, or

c) directions to pay;

issued by a federal, provincial, territorial or state authority? ................................................................................... “ Yes “ No

If “Yes”, complete Schedule “M”, section 4.

Item 17 - Related securities firms

Related securities firms and holdings

Are you a partner, director, or officer of a firm (other than your sponsoring firm) whose principal business is trading in or
advising on securities or exchange contracts (including commodity futures contracts and commodity futures options) or are
you a holder of 10 percent or more of the voting securities of any firm (including your sponsoring firm) whose principal
business is trading in or advising on securities or exchange contracts (including commodity futures contracts and
commodity futures options)?.................................................................................................................................. “ Yes “ No

If “Yes”, complete Schedule “N”.

Agent for Service

By submitting this form you certify that in each jurisdiction in which you have appointed an agent for service you have properly
executed the appointment of agent for service required by the regulator or the securities legislation of that jurisdiction.

Submission to Jurisdiction

By submitting this application you irrevocably and unconditionally submit to the non-exclusive jurisdiction of the judicial, quasi-
judicial and administrative tribunals of each jurisdiction to which you have submitted this application and any administrative
proceeding in that jurisdiction, in any action, investigation or administrative, criminal, quasi-criminal, penal or other proceeding
(each, a “Proceeding”) arising out of or relating to or concerning your activities as a registrant or an officer, partner or director
of a registrant under the securities legislation of the jurisdiction, and irrevocably waive any right to raise as a defence in any
Proceeding any alleged lack of jurisdiction to bring that Proceeding.

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 purposes of the administration and enforcement of certain provisions of the securities legislation in British
Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Québec, Nova Scotia, New Brunswick, Prince Edward Island,
Newfoundland and Labrador, Northwest Territories, Yukon Territory, and Nunavut.

By submitting this application you consent to the collection by the securities regulatory authority to which this application is
being submitted of the personal information contained in the application, 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 application or continued fitness for registration
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.
 FORM 33-109F4 REGISTRATION INFORMATION FOR AN INDIVIDUAL

The principal purpose for which this collection of personal information is to be used is to assess your suitability for registration
and to assess your continued fitness for registration in accordance with the applicable securities legislation.

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 in Schedule “O”. In
Québec, questions may also be addressed to the Commission d’accès à l’information du Québec (1-888-528-7741, web site:
www.cai.gouv.qc.ca).

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

The following certification is to be used when submitting this form in NRD format:

‘ I am making this submission as agent for the individual to whom this submission relates. By checking this box I certify
that all statements of fact in this submission were provided to me by the individual.

Both of the following certifications are to be used when submitting this form in paper format:

I, the undersigned, certify that I have read and that I understand the questions in this form and the Warning set out above.
I also certify that all statements of fact provided in this application are true.

Signature
Signature of applicant or non-registered individual Date

I, the undersigned, certify on behalf of the sponsoring firm that the individual will be engaged by the sponsoring firm as a
registered individual or a non-registered individual. I certify that I have, or a branch manager or another officer or partner
has, discussed the questions set out in this form with the individual and I am satisfied that the individual fully understands the
questions.

Signature
Signature of authorized officer or partner Date

________________________________________________
Firm name
 SCHEDULE “A”
Name

Item “ 1

Other names

Last name First name Second name Third name

(if applicable) (if applicable)

Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name).

When did you use this name? From: / To: /

(YYYY/MM) (YYYY/MM)

Last name First name Second name Third name

(if applicable) (if applicable)

Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name).

When did you use this name? From: / To: /

(YYYY/MM) (YYYY/MM)

Last name First name Second name Third name

(if applicable) (if applicable)

Provide the reasons for the use of this name (for example, marriage, divorce, court order, commonly used name).

When did you use this name? From: / To: /

(YYYY/MM) (YYYY/MM)
 SCHEDULE “B”
Residential address

Item “ 2

Previous addresses

A postal code (or ZIP code) and a telephone number are not required for any previous address.

Residential address:
(number, street, city, province, territory or state, country)

When did you live at this address? From: / To: /

(YYYY/MM) (YYYY/MM)

Residential address:
(number, street, city, province, territory or state, country)

When did you live at this address? From: / To: /

(YYYY/MM) (YYYY/MM)

Residential address:
(number, street, city, province, territory or state, country)

When did you live at this address? From: / To: /

(YYYY/MM) (YYYY/MM)

Residential address:
(number, street, city, province, territory or state, country)

When did you live at this address? From: / To: /

(YYYY/MM) (YYYY/MM)

Residential address:
(number, street, city, province, territory or state, country)

When did you live at this address? From: / To: /

(YYYY/MM) (YYYY/MM)
 SCHEDULE “C”
Individual categories

Item “ 6

Categories
Indicate, by checking the appropriate box, each category for which you are applying.
Alberta
q Salesperson q Shareholder
q Officer (Trading) q Branch Manager
q Officer (Non-Trading) q Officer (Advising)
q Partner (Trading) q Officer (Non-Advising)
q Partner (Non-Trading) q Junior Officer (Advising)
q Director q Partner (Advising)
q Partner (Non-Advising)

British Columbia
q Salesperson q Officer (Advising)
q Officer (Trading) q Officer (Non-Advising)
q Officer (Non-Trading) q Partner (Advising)
q Partner (Trading) q Partner (Non-Advising)
q Partner (Non-Trading) q Director (Advising)
q Director (Trading) q Director (Non-Advising)
q Director (Non-Trading) q Advising Employee
q Compliance Officer
q Shareholder
q Branch Manager

Manitoba
q Salesperson q Associate Advising Officer
q Officer (Trading) q Associate Advising Partner
q Officer (Non-Trading) q Associate Advising Director
q Partner (Trading) q Associate Advising Employee
q Partner (Non-Trading) q Non-trading
q Director (Trading) q Officer
q Director (Non-Trading) q Partner
q Branch Manager q Futures Contract Portfolio Manager
q Advising Officer q Associate Futures Contracts Portfolio Manager
q Advising Partner q Floor Trader
q Advising Director q Floor Broker
q Non-Advising Officer q Local
q Non-Advising Partner q Adviser
q Non-Advising Director
q Advising Employee
New Brunswick
q Salesperson q Compliance Officer
q Officer (Trading) q Officer (Advising)
q Officer (Non-Trading) q Officer (Non-Advising)
q Partner (Trading) q Junior Officer (Advising)
q Partner (Non-Trading) q Partner (Advising)
q Director q Partner (Non-Advising)
q Shareholder
Newfoundland and Labrador
q Salesperson q Officer (Advising)
q Officer (Trading) q Officer (Non-Advising)
q Officer (Non-Trading) q Director
q Director q Shareholder
q Shareholder q Partner (Advising)
q Partner (Trading) q Partner (Non-Advising)
q Partner (Non-Trading) q Branch Manager
q Branch Manager
 SCHEDULE “C”
Individual categories

Item “ 6

Categories
Northwest Territories
q Salesperson q Shareholder
q Officer (Trading) q Branch Manager
q Officer (Non-Trading) q Representative (Advising)
q Director q Officer (Advising)
q Partner (Trading) q Officer (Non-Advising)
q Partner (Non-Trading) q Partner (Advising)
q Sole Proprietor q Partner (Non-Advising)
Nova Scotia
q Salesperson q Officer (Advising)
q Officer (Trading) q Officer (Non-Advising)
q Officer (Non-Trading) q Associate Partner
q Sole Proprietor (Trading) q Partner (Advising)
q Director q Partner (Non-Advising)
q Partner (Trading) q Sole Proprietor (Advising)
q Partner (Non- Trading)

Nunavut
q Salesperson q Shareholder
q Officer (Trading) q Branch Manager
q Officer (Non-Trading) q Representative (Advising)
q Director q Officer (Advising)
q Partner (Trading) q Officer (Non-Advising)
q Partner (Non-Trading) q Partner (Advising)
q Sole Proprietor q Partner (Non-Advising)

Ontario
Except as indicated the following categories are available under the Securities Act and the Commodity Futures Act.
q Floor Trader q Associate Advising Representative (Securities Act
q Salesperson category only)
q Officer (Trading) q Officer (Advising)
q Officer (Non-Trading) q Officer (Non-Advising)
q Partner (Trading) q Associate Officer (Securities Act category only)
q Partner (Non-Trading) q Partner (Advising)
q Sole Proprietor (Trading) q Partner (Non-Advising)
q Director q Associate Partner (Securities Act category only)
q Advising Representative q Sole Proprietor (Advising)
q Shareholder
Prince Edward Island
q Salesperson q Branch Manager
q Officer (Trading) q Compliance Officer
q Officer (Non-Trading) q Counselling Officer (Officer)
q Partner (Trading) q Counselling Officer (Partner)
q Partner (Non-Trading) q Counselling Officer (Other)
q Director q Officer (Non-Advising)
q Shareholder q Partner (Non-Advising)

Québec
Dealer Adviser
q Salesperson (representative) q Representative (Advising)
q Officer q Officer
q Partner q Partner
q Director q Director
q Director (Non-Industry) q Director (Non-Industry)
q Branch Manager q Branch Manager
 SCHEDULE “C”
Individual categories
Item “ 6
Categories
Saskatchewan
q Salesperson q Employee (Advising)
q Officer (Trading) q Officer (Advising)
q Officer (Non-Trading) q Officer (Non-Advising)
q Partner (Trading) q Partner (Advising)
q Partner (Non-Trading) q Partner (Non-Advising)
q Director
Yukon
q Salesperson q Shareholder
q Officer (Trading) q Officer (Advising)
q Officer (Non-Trading) q Officer (Non-Advising)
q Partner (Trading) q Partner (Advising)
q Partner (Non-Trading) q Partner (Non-Advising)
q Director q Sole Proprietor (Advising)
q Sole Proprietor (Trading)
q Branch Manager
Investment Dealers Association of Canada
q Partner (Industry) q Registered Representative (Mutual Funds)
q Partner (Non-Industry) q Registered Representative (Retail)
q Director (Industry) q Registered Representative (Non-Retail)
q Director (Non-Industry) q Registered Representative Options (Retail)
q Officer (Trading) q Registered Representative Options (Non-Retail)
q Officer (Non-Trading) q Registered Futures Contract Representative Options
q Industry Investor (Retail)
q Non-Industry Investor q Registered Futures Contract Representative Options
q Chief Compliance Officer (Non-Retail)
q Ultimate Designated Person q Trader - CATS
q Alternate Designated Person q Trader - TradeCDNX
q Designated Registered Options Principal q Trader - Commodity Floor Trader
q Alternate Registered Options Principal q Associate Portfolio Manager - Securities
q Designated Registered Futures Options Principal q Associate Portfolio Manager - Security Options
q Alternate Registered Futures Options Principal q Associate Portfolio Manager - Commodity Futures
q Sales Manager Options
q Branch Manager q Portfolio Manager - Securities
q Co-Branch Manager q Portfolio Manager - Security Options
q Assistant Branch Manager q Portfolio Manager - Commodity Futures Options
q Futures Contract Options Supervisor
q Investment Representative (Mutual Funds)
q Investment Representative (Retail)
q Investment Representative (Non-Retail)
q Investment Representative Options (Retail)
q Investment Representative Options (Non-Retail)
q Investment Futures Contract Representative Options
(Retail)
q Investment Futures Contract Representative Options
(Non-Retail)
 SCHEDULE “D”
Address and Agent for Service

Item “ 7

Address for Service

1. Address for service

You must have one address for service in each province or territory in which you are now, or are applying to become, a
registered individual or non-registered individual. A post office box is not an acceptable address for service.

Address for service:

(number, street, city, province or territory, postal code)

Telephone number: ( ) Fax number: ( )

E-mail address:

2. Agent for service

If you have appointed an agent for service, provide the following information for the agent. The address for service
provided above must be the address of the agent named below.

Name of agent for service:

(if applicable)

Contact person:
Last name First name
 SCHEDULE “E”
Proficiency
Item ? 8
Course or examination information
Indicate each course and examination that you have successfully completed or for which you have received an exemption.

COURSE OR EXAMINATION DATE DATE EXEMPTED AND BY WHICH

COMPLETED JURISDICTION OR REGULATOR
(YYYY/MM/DD)
30-day Training Program
90-day Training Program
ACE Trader Exam
Agricultural Markets – Risk Management Course (ARM)
Branch Compliance Officers Course
Branch Manager's Examination Course (formerly the
Canadian Branch Managers Qualifying Examination)
Canadian Commodity Futures Examination
Canadian Commodity Supervisors Examination
Canadian Funds Course (Quebec only)
Canadian Futures Exam (Part 1)
Canadian Futures Exam (Part 2)
Canadian Investment Finance Course Part I
Canadian Investment Finance Course Part II
Canadian Investment Funds Course
Canadian Investment Management Program (Part 1)
Canadian Investment Management Program (Parts 2)
Canadian Options Course
Canadian Securities Course
CATS Examination-Oral
CATS Examination-Written
Certified Financial Planners Program
Chartered Financial Analyst Charter
Chartered Financial Analyst Course (Level I)
Chartered Financial Analyst Course (Level II)
Chartered Financial Analyst Course (Level III)
Commodity Futures Exam (Part 1)
Commodity Futures Exam (Part 2)
Conduct and Practices Handbook Course
Derivatives Fundamentals Course
Derivatives Operational Management Course
Effective Management Seminar
Energy Markets - Risk Management Course
Ensis Growth Fund Understanding Labour Sponsored
Investment Funds (Full Course)
Examination based on Manual for Registered
Representatives (RR Exam)
Fellow of the Canadian Securities Institute
Financial Markets Risk Management Course
 SCHEDULE “E”
Proficiency
COURSE OR EXAMINATION DATE DATE EXEMPTED AND BY WHICH
COMPLETED JURISDICTION OR REGULATOR
(YYYY/MM/DD)
Examination based on Manual for Registered
Representatives (RR Exam)
Futures Floor Trader Examination (Winnipeg Stock
Exchange)
Futures Licensing Course
General Securities Representative Examination (Series 7)
In-House Scholarship Training Program
Investment Funds Course
Investment Management Techniques
Labour Sponsored Investment Funds Course
National Commodity Futures Examination
New Entrants Examination
Officers’ Partners’ and Directors’ Course
Operations Course
Options Licensing Course
Options Strategies Course
Options Supervisors Course
Partners, Directors and Senior Officers Qualifying
Examination
Personal Financial Planning Diploma
Portfolio Management Techniques
Principles of Mutual Funds Investment Course
Professional Financial Planning Course
Professional Options Trader Examination
Real Estate Agent’s Pre-Licensing Course
Registered Options Principal's Qualifying Examination
Technical Analysis Course (TAC)
Trader Training Course
VCT Trader Exam
Wealth Management Techniques
Other, specify:

Other, specify:

Other, specify:

Other, specify:
 SCHEDULE “F”
Proficiency
Item “ 8

Exemption refusal
Complete the following for each exemption that was refused.

Which securities regulatory authority or self-regulatory organization refused to grant the exemption?

State the name of the course, examination or experience requirement:

State the reason given for not being granted the exemption:

Which securities regulatory authority or self-regulatory organization refused to grant the exemption?

State the name of the course, examination or experience requirement:

State the reason given for not being granted the exemption:
 SCHEDULE “G”
Current employment

Item “ 10

Employment information
Provide the information requested for each of your current business and employment activities, including those with your
sponsoring firm.

“ Unemployed

“ Full-time student

“ Employed or self-employed

From:
(YYYY/MM/DD)

You are only required to fill in the following if you have indicated above that you are employed or self-employed.

Name of business or employer:

Address of business or employer:

(number, street, city, province, territory or state, country)

Name and title of immediate supervisor:

Describe the type of business or employment and your duties. If you are seeking a type of registration for which specified
experience is required, provide details of that experience below (for example, level of responsibility, value of accounts
under direct supervision, and research experience):

Indicate the number of hours per week you will be devoting to this business or employment:

If the business or employment described above is with the sponsoring firm and if you are working less than 30 hours per
week for the firm, explain why you are working less than 30 hours per week for the firm:
 SCHEDULE “G”
Current employment
If the business or employment described above is not with the sponsoring firm, disclose any potential for confusion by
clients and any potential for conflicts of interest arising from your proposed activities as a registrant and the business or
employment described above (include whether the business is listed on an exchange):

SCHEDULE “H”
Previous employment

Item “ 11

Employment information

Provide the information requested for your previous business and employment activities for the 10-year period before the
date of this application. Include any periods of self-employment or unemployment during this period. Do not include
summer employment while you were a full-time student.

In addition, provide the information requested in respect of all of your securities or exchange contracts (including
commodity futures contracts and commodity futures options) business and employment activities during and prior to the
ten-year period.

“ Unemployed

“ Full-time student

“ Employed or self-employed

From: To:
(YYYY/MM/DD) (YYYY/MM/DD)

You are only required to fill in the following if you have indicated above that you are, or were, employed or self-employed.

Name of business or employer:

Address of business or employer:

(number, street, city, province, territory or state, country)

Name and title of immediate supervisor:

Describe the type of business or employment and your duties. If you are seeking a type of registration for which specified
experience is required, provide details of that experience below (for example, level of responsibility, value of accounts
under direct supervision, and research experience):
 SCHEDULE “I”
Resignations and terminations

Item “ 12

Resignation and Termination information

For each resignation or termination indicate below, (1) the name of the firm from which you resigned or were terminated,
(2) whether you resigned or were terminated, (3) the date you resigned or were terminated, and (4) the circumstances
relating to your resignation or termination (including whether the allegations were made by a client, sponsoring firm, self-
regulatory organization or regulatory authority).
 SCHEDULE “J”
Regulatory disclosure

Item “ 13

1. Securities regulatory authorities

a) For each registration or licence, indicate below (1) the securities regulatory authority with which you are, or were,
registered or licensed, (2) the type or category of registration or licence, and (3) the dates between which you
held the registration or licence.

b) For each registration or licence, indicate below (1) the name of the firm, (2) the securities regulatory authority with
which the firm is, or was, registered or licensed, (3) the type or category of registration or licence, and (4) the
dates between which you held the registration or licence.

c) For each registration or licence refused, indicate below (1) the party that was refused the registration or licence,
(2) the securities regulatory authority that refused the registration or licence, (3) the type or category of
registration or licence refused, (4) the date of the refusal, and (5) the reasons for the refusal.

d) For each exemption from registration denied, indicate below (1) the party that was denied the exemption, (2) the
securities regulatory authority that denied the exemption, (3) the date the exemption was denied, and (4) any
other information that you think is relevant or that is requested by the regulator.

e) For each order or disciplinary proceeding, indicate below (1) the party against whom the order was made or the
proceeding taken, (2) the securities regulatory authority that issued the order or that is, or was, conducting the
proceeding, (3) the date any notice of proceeding was issued, (4) the date any order or settlement was made, (5)
a summary of any notice, order or settlement (including any sanctions imposed), and (6) any other information
that you think is relevant or that is requested by the regulator.
 SCHEDULE “J”
Regulatory disclosure
2. Self-regulatory organizations
a) For each membership or participation, indicate below (1) the party that is, or was, a member or participating
organization, (2) the self-regulatory organization with which the party is, or was, a member or participating
organization, (3) the type or category of membership or participation, and (4) the dates between which the party
was a member or participating organization.

b) For each membership or participation refused, indicate below (1) the party that was refused membership or
participation, (2) the self-regulatory organization that refused the membership or participation, (3) the type or
category of membership or participation refused, (4) the date of the refusal, and (5) the reasons for the refusal.

c) For each order or disciplinary proceeding, indicate below (1) the party against whom the order was made or the
proceeding taken, (2) the self-regulatory organization that issued the order or that is, or was, conducting the
proceeding, (3) the date any notice of proceeding was issued, (4) the date any order or settlement was made, (5)
a summary of any notice, order or settlement (including any sanctions imposed), and (6) any other information
that you think is relevant or that is requested by the regulator.

3. Non-securities regulation

a) For each registration or licence, indicate below (1) the party is, or was, registered or licensed, (2) with which
regulatory authority, or under what legislation, the party is, or was, registered or licensed, (3) the type or category
of registration or licence, and (4) the dates between which the party held the registration or licence.

b) For each registration or licence refused, indicate below (1) the party that was refused registration or licensing, (2)
with which regulatory authority, or under what legislation, the registration or licence was refused, (3) the type or
category of registration or licence refused, (4) the date of the refusal, and (5) the reasons for the refusal.

c) For each order or disciplinary proceeding, indicate below (1) the party against whom the order was made or the
proceeding taken, (2) the regulatory authority that made the order or that is, or was, conducting the proceeding, or
under what legislation the order was made or the proceeding is being, or was, conducted, (3) the date any notice
of proceeding was issued, (4) the date any order or settlement was made, (5) a summary of any notice, order or
settlement (including any sanctions imposed), and (6) any other information that you think is relevant or that is
requested by the regulator.
 SCHEDULE “K”
Criminal disclosure

Item “ 14

Criminal, provincial and territorial offences

a) For each charge, indicate below (1) the charge, (2) the date of the charge, (3) any trial or appeal dates, and (4) the
court location.

b) For each conviction, indicate below (1) the offence, (2) the date of the conviction, and (3) the disposition (state any
penalty or fine and the date any fine was paid).

c) For each charge, indicate below (1) the name of the firm, (2) the charge, (3) the date of the charge, (4) any trial or
appeal dates, and (5) the court location.

d) For each conviction, indicate below (1) the name of the firm, (2) the offence, (3) the date of the conviction, and (4)
the disposition (state any penalty or fine and the date any fine was paid).
 SCHEDULE “L”
Civil disclosure

Item 9 15

Current and past civil proceedings

a) For each civil proceeding, indicate below (1) the party that is, or was, a defendant or respondent, (2) each plaintiff
in the proceeding, (3) whether the proceeding is pending, on appeal or final, (4) the jurisdiction in which the action
is being, or was, pursued, and (5) a summary of any disposition or settlement. (Disclosure must include those
actions settled without admission of liability.)

b) For each civil proceeding, indicate below (1) the firm that was a defendant or respondent in the proceeding, (2)
your relationship to the firm, (3) each plaintiff in the proceeding, (4) whether the proceeding is pending, on appeal
or final, (5) the jurisdiction in which the action is being, or was, pursued, and (6) a summary of any disposition or
settlement. (Disclosure must include those actions settled without admission of liability.)
 SCHEDULE “M”
Financial Disclosure

Item 9 16

1. Bankruptcy
For each event, indicate below (1) the party about whom this disclosure is being made, (2) any amounts currently owing,
(3) the creditors, (4) the status of the matter, (5) a summary of any disposition or settlement, and (6) any other information
that you think is relevant or that is requested by the regulator.

2. Solvency
For each event, indicate below (1) the party that failed to meet its financial obligation, (2) the amount that was owing at the
time the party failed to meet its financial obligation, (3) the party to whom the amount is, or was, owing, (4) any relevant
dates (for example, when payments are due or when final payment was made), (5) any amounts currently owing, and (6)
any other information that you think is relevant or that is requested by the regulator.

3. Surety Bond or Fidelity Bond

For each bond refused, indicate below (1) the name of the bonding company, (2) the address of the bonding company, (3)
the date of the refusal, and (4) the reasons for the refusal.

4. Garnishments, Unsatisfied Judgments or Directions to Pay

For each garnishment, unsatisfied judgement or direction to pay, indicate below (1) the amount that was owing at the time
the garnishment, judgement or direction to pay was rendered, (2) the party to whom the amount is, or was, owing, (3) any
relevant dates (for example, when payments are due or when final payment was made), (4) any amounts currently owing,
and (5) any other information that you think is relevant or that is requested by the regulator.
 SCHEDULE “N”
Related securities firms

Item “ 17

Section 1 - Related Securities Firms and Holdings

Indicate below (a) the name of the firm and (b) your relationship to the firm.

a) Firm name:

b) Relationship to the firm and period of relationship:

“ Partner From: / To: / (if applicable)

(YYYY/MM) (YYYY/MM)

“ Director From: / To: / (if applicable)

(YYYY/MM) (YYYY/MM)

“ Officer From: / To: / (if applicable)

(YYYY/MM) (YYYY/MM)

“ Holder of voting From: / To: / (if applicable)

securities over 10 (YYYY/MM) (YYYY/MM)
percent

If you are a holder of 10 percent or more of the voting securities of the firm, complete (c), (d), (e), (f), (g) and (h).

c) State the number, value, class and percentage of securities or the amount of partnership interest you own or
propose to acquire upon approval. If acquiring shares upon approval, state source (for example, treasury shares,
or if upon transfer, state name of transferor).

d) State the value of subordinated debentures or bonds of the firm to be held by you or any other subordinated loan to
be made by you to the firm (if applicable):

e) If another party has provided you with funds to invest in the firm, identify the party and state the relationship
between you and that party:
 SCHEDULE “N”
Related securities firms

f) Are the funds to be invested (or proposed to be invested) guaranteed directly or indirectly by any person
or firm? .............................................................................................................................................. “ Yes “ No

If “Yes”, identify the party and state the relationship between you and that party:

g) Have you either directly or indirectly given up any rights with respect to such securities or partnership interest, or do
you, on approval of this application, intend to give up any such rights (including by hypothecation, pledging or
depositing as collateral the securities or partnership interest with any institution or person)? ........ “ Yes “ No

If “Yes”, identify the party, state the relationship between you and that party and describe the rights that have been or will
be given up:

h) Is a person other than you the beneficial owner of the shares, bonds, debentures, partnership units or other notes
held by you? ........................................................................................................................ “ Yes “ No

If “Yes”, complete (i), (j) and (k).

i) Name of beneficial owner:

Last name First name Second name Third name

(if applicable) (if applicable)

j) Residential address:

(number, street, city, province, territory or state, country, postal code)

k) Occupation:
 SCHEDULE “O”
Notice and collection and use of personal information
Contact Information
Alberta British Columbia

Alberta Securities Commission, British Columbia Securities Commission

4th Floor, 300 B 5th Avenue S.W. P.O. Box 10142, Pacific Centre
Calgary, AB T2P 3C4 701 West Georgia Street
Attention: Information Officer Vancouver, BC V7Y 1L2
Telephone: (403) 297-6454 Attention: Freedom of Information Officer
Telephone: (604) 899-6500 or (800) 373-6393 (in BC)
Manitoba New Brunswick

The Manitoba Securities Commission Securities Administration Branch

1130-405 Broadway PO Box 5001
Winnipeg, MB R3C 3L6 606, 133 Prince William Street
Attention: Director – Legal Saint John, NB E2L 4Y9
Telephone: (204) 945-4508 Attention: Deputy Administrator, Capital Markets
Telephone: (506) 658-3021
Newfoundland and Labrador Nova Scotia

Securities Commission of Newfoundland and Labrador Nova Scotia Securities Commission

P.O. Box 8700, 2nd Floor, West Block 2nd Floor, Joseph Howe Building
Confederation Building 1690 Hollis Street
St. John's, NF A1B 4J6 P.O. Box 458
Attention: Director of Securities Halifax, NS B3J 3J9
Tel: (709) 729-4189 Attention: FOI Officer
Telephone: (902) 424-7768
Northwest Territories Nunavut

Government of the Northwest Territories Legal Registries Division

P.O. Box 1320 Department of Justice
Yellowknife, NWT X1A 2L9 Government of Nunavut
Attention: Deputy Registrar of Securities P.O. Box 1000 Station 570
Telephone: (867) 920-8984 Iqaluit, NU X0A 0H0
Attention: Deputy Registrar of Securities
Telephone: (867) 975-6190
Ontario Prince Edward Island

Ontario Securities Commission Securities Registry

Suite 1903, Box 55 Office of the Attorney General B Consumer, Corporate and
20 Queen Street West Insurance Services Division
Toronto, ON M5H 3S8 P.O. Box 2000
Attention: FOI Coordinator Charlottetown, PE C1A 7N8
Telephone: (416) 593-8314 Attention: Deputy Registrar of Securities
Telephone: (902) 368-4569
Québec Saskatchewan

Commission des valeurs mobilières du Québec Saskatchewan Securities Commission

Stock Exchange Tower 800 B1920 Broad Street
P.O. Box 246, 22nd Floor Regina, SK S4P 3V7
800 Victoria Square Attention: Director
Montréal, PQ H4Z 1G3 Telephone: (306) 787-5842
Attention: Responsable de l’accès à l’information
Telephone: (514) 940-2150 or (800) 361-5072 (in Québec)
Yukon

Department of Community Services Yukon

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