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D-9.2, r. 8 - Regulation respecting distribution without a representative
Schedule
Disposition versions
Schedule 3
(s. 4)
NOTICE OF SPECIFIC CONSENT
YOU ARE FREE TO GRANT OR REFUSE THIS CONSENT
Section 92 and 437 of the Act respecting the distribution of financial products and services (chapter D-9.2)
_________________________________________________________________________________
| |
| WHAT YOU MUST KNOW: |
| |
| · At this date, we hold certain information relating to you. |
| |
| · We require your consent to allow some of our clerks to have access to this |
| information. |
| |
| · These clerks will also have access to any update of the information done |
| during the period of validity of the consent. |
| |
| · These clerks will use the information available in order to solicit you for |
| the purchase of new financial products and services. |
| |
| YOU ARE FREE TO SET THE PERIOD OF VALIDITY OF YOUR CONSENT |
| |
| |
| · If you grant consent for an undetermined period of time, you may at any time |
| terminate it by revoking it. At the end of this form, you will find |
| a revocation notice model that you may use for this purpose, or as a basis |
| for preparing your own notice. |
| |
| · If you wish to grant consent for a limited period of time, you may do so by |
| determining this period yourself. This form provides, in the “specific |
| consent” section, a place where you may write down the period of validity |
| desired. |
| |
| THE ACT RESPECTING THE DISTRIBUTION OF FINANCIAL PRODUCTS AND |
| SERVICES GIVES YOU IMPORTANT RIGHTS. |
| |
| |
| Without this specific consent, the distributor may not use this information |
| for a purpose other than the purpose for which it was collected. The |
| distributor cannot compel you to give your consent or refuse to do business |
| with you if you refuse to give it. Section 94 of the Act protects you. For |
| further information, contact the Autorité des marchés financiers at: |
| (418) 525-0337 or 1-877-525-0337. |
|_________________________________________________________________________________|
| |
| WHAT YOU MUST KNOW: |
| |
| · At this date, we hold certain information relating to you. |
| |
| · We require your consent to allow some of our clerks to have access to this |
| information. |
| |
| · These clerks will also have access to any update of the information done |
| during the period of validity of the consent. |
| |
| · These clerks will use the information available in order to solicit you for |
| the purchase of new financial products and services. |
| |
| YOU ARE FREE TO SET THE PERIOD OF VALIDITY OF YOUR CONSENT |
| |
| |
| · If you grant consent for an undetermined period of time, you may at any time |
| terminate it by revoking it. At the end of this form, you will find |
| a revocation notice model that you may use for this purpose, or as a basis |
| for preparing your own notice. |
| |
| · If you wish to grant consent for a limited period of time, you may do so by |
| determining this period yourself. This form provides, in the “specific |
| consent” section, a place where you may write down the period of validity |
| desired. |
| |
| THE ACT RESPECTING THE DISTRIBUTION OF FINANCIAL PRODUCTS AND |
| SERVICES GIVES YOU IMPORTANT RIGHTS. |
| |
| |
| Without this specific consent, the distributor may not use this information |
| for a purpose other than the purpose for which it was collected. The |
| distributor cannot compel you to give your consent or refuse to do business |
| with you if you refuse to give it. Section 94 of the Act protects you. For |
| further information, contact the Autorité des marchés financiers at: |
| (418) 525-0337 or 1-877-525-0337. |
|_________________________________________________________________________________|
The information we hold pertaining to you, at this date, was collected as part of:
(purposes of the file)
Here are the required categories of information that we would like one of our clerks to use and the products and services he may offer you. For a fuller description of each category, you may refer to the back of this sheet.
Please authorize each category of information requested.
_________________________________________________________________________________
| | | | |
| Required information | For which products | Client’s | |
| category to be | and services?2 | Authorization3 | Initiales4 |
| accessed1 | | | |
|________________________|______________________|__________________|______________|
| | | | |
| To be filled by the | To be filled by the | □ Yes □ No | |
| distributor | distributor | | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| |
| Instructions for the distributor (duplication not required): |
| |
| |
| 1. The distributor must describe each category on the reverse side of |
| this sheet. |
| |
| 2. The distributor must specify the nature of the products and services it |
| it wishes to offer the client. Each information category must be |
| associated with a specific purpose. Where a category serves several |
| purposes, the distributor must repeat it for each purpose. |
| |
| 3. The client may give his or her authorization by telephone, provided both |
| parties can identify each other. In such case, this form shall serve as a |
| script for the officer, who will also read the detailed description of each |
| category to the client. The distributor must fill out this form and send |
| it to the client within 10 days of obtaining the verbal consent. |
| |
| 4. If in electronic form, the initials may be replaced by a confirmation |
| window. However, the notice of consent must be made available to the |
| client by any means allowing the reading or printing thereof. |
|_________________________________________________________________________________|
| | | | |
| Required information | For which products | Client’s | |
| category to be | and services?2 | Authorization3 | Initiales4 |
| accessed1 | | | |
|________________________|______________________|__________________|______________|
| | | | |
| To be filled by the | To be filled by the | □ Yes □ No | |
| distributor | distributor | | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| | | | |
| | | □ Yes □ No | |
|________________________|______________________|__________________|______________|
| |
| Instructions for the distributor (duplication not required): |
| |
| |
| 1. The distributor must describe each category on the reverse side of |
| this sheet. |
| |
| 2. The distributor must specify the nature of the products and services it |
| it wishes to offer the client. Each information category must be |
| associated with a specific purpose. Where a category serves several |
| purposes, the distributor must repeat it for each purpose. |
| |
| 3. The client may give his or her authorization by telephone, provided both |
| parties can identify each other. In such case, this form shall serve as a |
| script for the officer, who will also read the detailed description of each |
| category to the client. The distributor must fill out this form and send |
| it to the client within 10 days of obtaining the verbal consent. |
| |
| 4. If in electronic form, the initials may be replaced by a confirmation |
| window. However, the notice of consent must be made available to the |
| client by any means allowing the reading or printing thereof. |
|_________________________________________________________________________________|
In accordance with the Act respecting the protection of personal information in the private sector (chapter P-39.1), you may request to be given access to the information we hold pertaining to you.
SPECIFIC CONSENT
Having read the above, I, the undersigned,__________(name of client)__________ consent to use of the information held by the distributor for the purposes indicated above.
This authorization will be valid until revoked or for the following period:
______________________________________________
DD/MM/YY (to be filled out by the client)
I may revoke this consent at any time by sending a notice.
I may use the attached model notice for this purpose or as a basis for preparing my own notice.
____________________________________________ ___________________________________________
(signature of client) (date of signature of the consent)
(client identification, address, folio or contract no., etc.)
-----------------------------------------------------------------------------------------------------------------------------------------
I HEREBY REVOKE THE SPECIFIC CONSENT GIVEN TO THE DISTRIBUTOR BY THE FOLLOWING NOTICE
To: ___________________________________________
(name of distributor)
______________________________________________
(address of distributor)
On: ___________________________________________
I, the undersigned, __________(name of client)__________ hereby notify you that
I am canceling the specific consent authorizing the communication of my personal information for new purposes.
Consent givent to you on: ______________________________________________________________________
(date of consent)
____________________________________________ _____________________________________________
(name of client) (signature of client)
(client identification, address, folio or contract no., etc.)
