Nova Scotia Securities Commission Complaint Form

Name:______________________________________________________________________
(First, last and middle name-please print)

Address:____________________________________________________________________

City:_______________________________

Province:___________________________

Postal Code:________________________

Home Telephone: (____________) __________________

Business Telephone: (__________) _________________

Fax: (____________) _________________

Email:_____________________________________________________________________

Account Information

Name of dealer or company:___________________________________________________

Name of sales person:________________________________________________________

Number of accounts at dealer or company:_______

Have you contacted your salesperson in writing regarding this complaint?

Please circle one : Yes No

Have you contacted the dealer or company's head office in writing regarding this complaint?

Please circle one: Yes No

Have you contacted the appropriate Self-Regulatory Organization (SRO, i.e. MFDA/IDA)?

Please circle one : Yes No

Complaint Summary: Please provide a chronological summary of your complaint and attach any relevant documentation you may have.

_________________________________________________________________________________

If this space is insufficient, please attach additional pages.

Signature________________________________________________________________________

Date ________________________________

Please fax to the NSSC Enforcement Staff: 902-424-3538 or mail: Enforcement Staff, Nova Scotia Securities Commission, PO Box 458, Halifax, NS B3J 2P8.