Government of Ontario: Ministry of Government and Consumer Services

Consumer Services Operations Division
77 Wellesley Street West
PO Box 450
Toronto ON M7A 2J6
Telephone:    416-326-8800
Toll free:        1-800-889-9768
TTY:              416-229-6086
TTY toll free: 1-877-666-6545

Application for Registration or Appointment
(Business) - New, Reinstatement or Renewal

Note to Applicants:

Bailiffs: complete sections
Sole Proprietor 1 to 4; 6; 7; 9 to 19
Partnership 1 to 4; 6; 7; 9 to 19
Corporation 1 to 7; 9 to 19

Collection Agencies and Consumer Reporting Agencies: complete sections
Sole Proprietor 1 to 4; 6; 9 to 19
Partnership 1 to 4; 6; 9 to 19
Corporation 1 to 6; 9 to 19
Branch 1 to 4; 8; 9 to 19

FOR CPB OFFICE USE ONLY

File Number

Checked By
Checked By Date (yyyy/mm/dd)

Approved By
Approved By Date (yyyy/mm/dd)

1. The applicant hereby applies for the following: check appropriate type
Application for:

Bailiff Appointment, Bailiffs Act
Collection Agency Registration, Collection Agencies Act
Consumer Reporting Agency Registration, Consumer Reporting Act

2. Business Application Type

Sole Proprietorship Partnership Corporation Branch (not applicable to Bailiffs)

3. Application Type

New Reinstatement Renewal (not applicable to Bailiffs)
For reinstatement or renewal give previous registration number

4. For the purpose of this application the applicant provides the following information

Full Legal Name of Applicant
Ontario Corp. Number
Business Registration Number
Single Business Number
Carrying on Business as

Business Address

Unit/Suite/Apt.
Street Number
Street Name
PO Box Number
City/Town
Province
Postal Code

Telephone Number (incl. Area Code)

Fax Number (incl. Area Code)

E-mail Address
Chief Officer, Manager or Contact Person

Contact Telephone Number (incl. Area Code)

Mailing Address (if different from Business Address)

Unit/Suite/Apt.
Street Number
Street Name
PO Box Number
City/Town
Province
Postal Code

If a Sole Proprietor, are you a Canadian Citizen?

Yes No If “No”; attach valid employment authorization document.

5. For Corporations Only (if the shareholder is another Corporation include a fully completed form)

Date of Incorporation (yyyy/mm/dd)

Jurisdiction of Incorporation

Ontario Other (specify)

Name of Shareholder
(include Corporation Number if applicable)
Address of Shareholder
Occupation of Shareholder

Total No. of equity (voting) shares issued to date

Is the corporation entitled to offer its shares to the public?

Yes No

Are any of the equity (voting) shares held for a beneficial Shareholder?
If yes, attach full particulars

Yes No

6. For Collection Agencies

Name of Financial Institution where trust account is maintained

Trust Account Number

Address of Financial Institution

Unit/Suite/Apt.
Street Number
Street Name
PO Box Number
City/Town
Province
Postal Code

7. For Bailiffs Only

Have you attached an ORIGINAL bond in the amount of $5,000.00?

Yes No

This application for appointment is made for
(Name of territorial division)

NOTE: List qualifications to act as a bailiff on a separate sheet and include résumé.
If the application is in respect of a corporation, include qualifications and résumé of each active officer and director.

List the circumstances, which indicate that a bailiff is needed for public convenience in the territorial division where applicant wishes to be appointed.

8. Notices and Consent under the Freedom of Information and Protection of Privacy Act (Applicant)

I/We understand that in order to complete and verify the information provided in this application, Ministry of Government and Consumer Services, Consumer Services Operations Division may consult with licensing or regulatory authorities, government regulators or other law enforcement agencies in or out of Canada, the Registrar of Bankruptcies, credit bureaus, professional and industry associations, former or current employers, employers for whom I may be associated with while this appointment, licence or registration is valid and may collect additional relevant information.

I/We also understand that the information collected pursuant to this application or in relation to the conduct as a licensee, registrant or appointee under the Act to which this application is made, may be shared with regulating authorities or law enforcement agencies in other jurisdictions and that such information may be used in determining the license, registration or appointment status in all jurisdictions in which the applicant is licensed, registered or appointed or has applied to be licensed, registered or appointed.

I/We consent to the collection and use of this information to determine whether I am/we are and remain, or the applicant is and remains qualified for licensing, registration or appointment in all jurisdictions.

I/We further consent to the Ministry informing my/our current, subsequent or intended employer(s) of any action taken and of any information gathered in relation to this licence, registration or appointment.

Dated at this day of 20 .

Signature of Applicant or Authorized Signing Officer

Print Name in Full

NOTE: For Corporations, an officer must sign this application.
For Partnerships, each partner in a partnership must sign this application.
For a Sole Proprietorship, the sole proprietor must sign this application.

The public official who can answer questions about the collection of this information is:

Ministry of Government and Consumer Services
Consumer Services Operations Division
77 Wellesley Street West
PO Box 450
Toronto ON M7A 2J6
Telephone: 416-326-8800
Toll free: 1-800-889-9768
TTY: 416-229-6086
TTY toll free: 1-877-666-6545

9. Key Individuals

(Attach a completed copy of this page (page 3) and the following pages (page 4 & 5), for each officer, director, partner, sole proprietor)

Name

Last Name
First Name
Initial

Canadian Resident

Yes No

Date of Birth (yyyy/mm/dd)

Sex M F

Position Held

Shareholder Director Partner Sole Proprietor Other (specify)

For Bailiff or Collection Agency Applicants only
(partner, sole proprietorship or active officer or director
of a corporate application must pass an examination)

I will be active in the business to which this application pertains
On (date) I successfully passed the Bailiff examination.
On (date) I successfully passed the Collection Agency examination

Residential Address

Unit/Suite/Apt.
Street Number
Street Name
PO Box Number
Registration Number
City/Town
Province
Postal Code

Telephone Number (incl. Area Code)

Fax Number (incl. Area Code)

E-mail Address

10. – 18. Key Individuals and Applicants

If the answer to any of the following questions is “YES” attach full details on a separate signed and dated sheet.
Also attach any relevant documentation

It is a serious offence to make a false statement in this application. A false statement may delay the processing of this application and result in the refusal of the application and possible charges.

10. Will you be engaged, occupied, employed or associated directly or
indirectly, in any other business, occupation or profession?
Check Appropriate Response

No
Yes. Indicate full details on a separate sheet.
Previously Reported

11. Are you registered, licenced or appointed under this or any other
legislation in any province, territory, state or country? (other than related
to a driver’s licence)
Check Appropriate Response

No
Yes. Indicate type, jurisdiction, registration, licence or appointment number on a separate sheet.
Previously Reported

12. Do you currently have any unpaid judgment(s) outstanding against you?
Are you or were you an officer, director or controlling shareholder of a
corporation, which has any unpaid judgment(s) outstanding?
Check Appropriate Response

No
Yes. Submit a copy of each judgment. State amount outstanding and repayment arrangements.
Previously Reported

13. Have you ever had a registration, licence or appointment refused,
suspended, revoked or cancelled? (other than related to a driver’s licence)
Check Appropriate Response

No
Yes. Indicate type, jurisdiction, registration, licence or appointment number on a separate sheet.
Previously Reported

14. Have you ever been an officer, director or controlling shareholder of a
corporation that has had a registration, licence or appointment, refused,
suspended, revoked or cancelled?
Check Appropriate Response

No
Yes. Indicate type, jurisdiction, registration, licence or appointment number on a separate sheet.
Previously Reported

15. Have you, in the past ten (10) years, been involved in bankruptcy
proceedings, or are you now or have you been an officer, director or
controlling shareholder of a corporation which has in the last ten (10)
years been declared bankrupt or is currently a party to bankruptcy
proceedings?
Check Appropriate Response

No
Yes. Attach assignment or discharge papers and a list of creditors
Previously Reported

16. Have you ever been convicted of an offence under any law of any
province, territory, state or country, or are you currently the subject of
any charges?
(You do not have to disclose any offence for which a pardon has been
granted under the Criminal Records Act and which has not been revoked.
(A pardon is not granted simply because of the passage of time.) You do
not have to disclose convictions under the Young Offenders Act, the
Juvenile Delinquents Act or minor traffic violations such as speeding or
parking tickets.)
Check Appropriate Response

No
Yes. Indicate full details on a separate sheet.
Previously Reported

17. Have you ever been an officer, director or controlling shareholder of a
corporation which has been convicted of an offence under any law of any
province, territory, state or country, or is currently the subject of any
charges?
Check Appropriate Response

No
Yes. Indicate full details on a separate sheet.
Previously Reported

18. Have you ever had an employment or business relationship terminated for
breach of trust or confidentiality, deceit, fraud, theft, forgery,
misappropriation of funds, harassment or assault or other similar
conduct?
Check Appropriate Response

No
Yes. Indicate full details on a separate sheet.
Previously Reported

I hereby certify that the information provided is, to the best of my knowledge and belief, true.
Dated at this day of 20 .
Signature of Applicant

Print Name in Full

19. Notices and Consent under the Freedom of Information and Protection of Privacy Act (Individual)

I understand that in order to complete and verify the information provided in this application, Ministry of Government and Consumer Services, Consumer Services Operations Division may consult with licensing or regulatory authorities, government regulators or other law enforcement agencies in or out of Canada, the Registrar of Bankruptcies, credit bureaus, professional and industry associations, former or current employers, employers for whom I may be associated with while this appointment, licence or registration is valid and may collect additional relevant information.

I also understand that the information collected pursuant to this application or in relation to the conduct as a licensee, registrant or appointee under the Act to which this application is made, may be shared with regulating authorities or law enforcement agencies in other jurisdictions and that such information may be used in determining the license, registration or appointment status in all jurisdictions in which the applicant is licensed, registered or appointed or has applied to be licensed, registered or appointed.

I consent to the collection and use of this information to determine whether I am and remain, or the applicant is and remains qualified for licensing, registration or appointment in all jurisdictions.

I further consent to the Ministry informing my current, subsequent or intended employer(s) of any action taken and of any information gathered in relation to this licence, registration or appointment.

Dated at this day of 20 .
Signature of Applicant

Print Name in Full

The public official who can answer questions about the collection of this information is:

Ministry of Government and Consumer Services
Consumer Services Operations Division
77 Wellesley Street West
PO Box 450
Toronto ON M7A 2J6
Telephone: 416-326-8800
Toll free: 1-800-889-9768
TTY: 416-229-6086
TTY toll free: 1-877-666-6545

Government of Ontario: Ministry of Government and Consumer Services

Application for Registration or Appointment (Business) - New, Reinstatement or Renewal

Application for Registration or Appointment
(Business) - New, Reinstatement or Renewal