Product Disclosure

Third Party Statement

Third Party Determination Statement


Account Name: __________________________________________________________________________

Branch and Account #: ____________________________________________________________________

CSG Representative Name: _________________________________________________________________

RR code (if applicable): _____________ Date: ___________________ Time of call: ___________________


A "Third Party" is defined as anyone other than TD Waterhouse Canada Inc. ("TD Waterhouse") or The Toronto-Dominion Bank (or any of their affiliates)or the customer(s) designated as the signing officer(s) for the account, who would make frequent deposits to, or would receive financial benefits from the account, and/or exerts control over the assets in the account.

For an account that is to be used by or on behalf of a third party, please complete the following:

Third Party's Name * Third Party's Address Third Party's Principal Business or Occupation Relationship to Account Holder Date of Birth
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
If additional space is required, please use the back of this form.
* If the third party is a business, document the business' incorporation number and its place of issuance.

Certification:

Please read and sign the following:

I/we, _____________________________________________________________________ (Account Holder(s)), having signing authority over the account noted above, confirm that the above noted account will be used by or on behalf of the person(s) listed above. If there are any changes to the above list, I will advise TD Waterhouse (and/or any of it's affiliates) in writing immediately.


     
Authorized Signature   Date
 
 
     
Authorized Signature   Date


TD Waterhouse Canada Inc. is a subsidiary of The Toronto-Dominion Bank. TD Waterhouse Canada Inc. - Member of the Canadian Investor Protection Fund.
® / The TD logo and other trade-marks are the property of The Toronto-Dominion Bank or a wholly-owned subsidiary, in Canada and/or other countries.

592094 (0314)