Section 4. Information Required On Individual Signing This Form
1. Are you a partner, director, officer or employee of a Member firm of the Investment Industry Regulatory
Organization of Canada or a relative of any such individual living in the same household?
Yes No
If yes, please list the name of the Member firm and provide
the required authorization letter from the Member firm:
2. Is there any other person/organization/entity who has a financial interest in this account or who exerts
control over the assets in the account?
Yes No
If yes, please complete and attach the supplemental
form Third Party Determination Statement.
3. Are you or your spouse/partner a director, senior officer, 10% shareholder or more, or insider of any
reporting issuer?
You:
Yes No
If yes, please indicate the name of issuer(s):
Spouse/Partner:
Yes No Not Applicable
If yes, please indicate the name of issuer(s):
4. Do you or your spouse/partner, as individuals or in combination with others, control (directly or
indirectly) more than 20% of the voting securities of any reporting issuer?
Yes No
If yes, please indicate the name of issuer(s):
Please Note If I have answered “yes” to questions 3 or 4, I am aware of my obligations to report purchases or sales
and possible restrictions on trading these securities according to applicable securities legislation.
Section 5. Update Trading Authorities/Members/Partners/Officers/Directors
1. Do you need to make a change to the appointed Trading Authorities/Members/Partners on this account?**
Yes No
2. Do you need to make a change to the signing Officers/Directors on this accounts?**
Yes No
3. Do you need to make a change to the Beneficial Owners on this account?**
Yes No
**If you have answered 'YES' to any of these questions, call 1-800-769-2560 or 416-977-1255 and speak with
an investment services representative on additional documentation required.
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