Personal Information Form
As a matter of practice, OTC Markets Group requires submission of the Personal Information Form (PIF) from individuals associated with Companies in the following situations:
- OTCQX Companies and Applicants - Officers, directors and Control Persons, others upon request
- OTCQB Companies and Applicants - Officers, directors, Control Persons, OTCIQ users, others upon request
- OTCQX Sponsor Applicants
- OTC Disclosure & News Service Subscribers or Applicants - Upon request by officers, directors, Control Persons, billing contacts, OTCIQ users or other contacts of companies desiring to access services available to Pink companies.
- Change of Control - OTC Markets may request a PIF for individuals connected to any company undergoing a change of control.
- Ongoing Compliance or Surveillance Reviews - OTC Markets may request a PIF for individuals connected to any company in relation to an ongoing review related to any surveillance or compliance concerns, promotional activity surrounding an issuer, or surrounding a Caveat Emptor designation.
- Other - From time to time, OTC Markets may require submission of a PIF form by service providers, including investors relations, promoters, attorneys, etc.
Failure to submit a PIF may result in the removal of the Company from OTQCX or OTCQB or denial
of access to services provided to Pink companies. Capitalized terms are defined in the "Definitions"
section beginning on page 8.
INSTRUCTIONS
OTC Markets Group will Only Process Complete Submissions. Failure to respond to all questions accurately and completely may result in the return of the PIF, may delay the processing of the related application, and/or may result in the denial of the application.
If you answer "Yes" to any question in Section 2: Disclosure Information, you must provide an explanation as requested. OTC Markets Group may subsequently require you to provide additional information on the Personal Information Form - Additional Disclosure Reporting.
Data Privacy. OTC Markets Group takes the security of your information very seriously. Please read the Privacy Policy Statement on page 9 to learn about your data privacy rights and how the information that you provide on this form is used by OTC Markets Group.
Submission: This Personal Information Form and any exhibits or attachments must be signed and emailed to issuers@otcmarkets.comor delivered to OTC Markets Group Inc., 100 M Street, Suite 220, Washington D.C., 20003.
OTC Markets Group Inc. | Page 1 of 9 |
Personal Information Form (v. 3.0 March 20, 2019) |
SECTION ONE: PERSONAL INFORMATION
1. Identification of Individual Completing this Form
First Name | Middle Name | Last Name |
NICHOLAS | JOHN | SMEDLEY |
Date of Birth (MM/DD/YYYY) | ||
20/01/1983 | ||
nicholas@smedley.com.au | ||
Phone | ||
0447 074 160 |
Other names - Please list any other names currently or previously known by, including legal names, assumed names or nicknames:
N/A
Marital Status | Full Name of Spouse | Occupation of Spouse |
MARRIED | ALICE VAN SMEDLEY | INTERIOR DESIGNER |
Residential History - Provide all residential addresses for the past five years, starting with your current principal residential address. If you are unable to identify the complete address, the municipality, state/province and country must be identified
STREET ADDRESS, CITY, STATE/PROVINCE, ZIP CODE & | FROM | TO | ||
COUNTRY | MM | YYYY | MM | YYYY |
36 THOMAS STREET, HAMPTON VIC 3188 | 03 | 2017 | 07 | 2022 |
2. Associated Company, Issuer or Service ProviderCompany Name: RESPIRI LIMITED
Present or Planned position with the Company. Check all that apply:
Director | Date appointed/elected (MM/DD/YYYY): | ||
Officer | Date appointed/elected (MM/DD/YYYY): | ||
5% Beneficial Owner | |||
Other | Provide Details: | EXECUTIVE CHAIRMAN |
OTC Markets Group Inc. | Page 2 of 9 |
Personal Information Form (v. 3.0 March 20, 2019) |
Securities Holdings. List all securities holdings in the Company, including options, for which you, or an entity in which you have an ownership interest, hold a beneficial interest, including the amounts held, percentage interest and whether the certificates or other documents evidencing the securities contain a legend (1) stating that the shares have not been registered under the Securities Act and (2) setting forth or referring to restrictions on transferability and sale of the shares.
NAME AND CLASS OF | AMOUNT HELD AND | |
SECURITY | PERCENTAGE INTEREST | LEGEND DETAILS |
RSH SHARES PURCHASED | 5,162,394.00 | |
3. Citizenship
Are you a U.S. Citizen? | Yes | No |
If Yes, provide your U.S. Social Security number (first 5 digits):
Do you hold citizenship in any country other than the U.S.? | Yes | No |
If Yes, which country(ies)?: | AUSTRALIA & UNITED | |
KINGDOM | ||
Provide passport or another identification number for the country(ies): | PB4439972 |
4. Employment History
Provide your employment history for the ten yearsimmediately prior to the date of this Personal Information Form, starting with your current employment. Use an attachment if necessary.
EMPLOYER | FROM | TO | ||||
EMPLOYER NAME | ADDRESS | POSITION HELD | MM | YYYY | MM | YYYY |
REFER TO PAGE 10 | ||||||
OTC Markets Group Inc. | Page 3 of 9 |
Personal Information Form (v. 3.0 March 20, 2019) |
5. Involvement with other Issuers
Are you, or have you during the last ten yearsever been, in any
jurisdiction, an officer, director, promoter, Control Person or Yes No consultant for any issuer of securities?
If Yes, provide the names of each issuer and the markets on which their securities were traded (e.g., NYSE, NASDAQ, NYSE MKT, OTC Markets, private). State the position(s) held and the period(s) during which you held the position(s). Use an attachment if necessary.
NAME OF | MARKET | FROM | TO | |||
ISSUER | TRADED ON | POSITION(S) HELD | MM | YYYY | MM | YYYY |
N/A | N/A | N/A | ||||
6. Professional Designations and Memberships
FINRA or SEC Registration - Have you ever been a licensed | ||
registered representative with FINRA or registered as an | Yes | No |
investment advisor with the SEC or a U.S. state? |
If Yes, provide the CRD number and/or SEC Number:
Professional Designations and Licenses - Provide any additional professional designation, licenses, affiliations, and associations to which you belong. For attorneys, include all Bar affiliations and memberships, past or present.
PROFESSIONAL | GRANTOR OF | DATE GRANTED | ACTIVE? | |||
DESIGNATION | DESIGNATION AND | |||||
AND MEMBERSHIP NUMBER | JURISDICTION | MM | DD | YYYY | YES | NO |
N/A | N/A | |||||
7. Education History
Provide your post-secondary (after high school) educational history, starting with the most recent:
SCHOOL | LOCATION | DEGREE OR DIPLOMA | YEAR OBTAINED |
Monash University | Melbourne | Bachelor of Commerce | 2003 |
OTC Markets Group Inc. | Page 4 of 9 |
Personal Information Form (v. 3.0 March 20, 2019) |
SECTION TWO: DISCLOSURE INFORMATION
8. Criminal Actions
YES NO
-
Have you or any Affiliate ever been convicted of or pled guilty or nolo contendere
("no contest") in a U.S. federal, state, non-U.S. or military court to a misdemeanor involving: (i) investments or an investment-related business, (ii) any fraud, false statements or omissions, (iii) wrongful taking of property, (iv) bribery, (v) perjury, (vi) forgery, (vii) counterfeiting, (viii) extortion, or (ix) a conspiracy to commit any of these offenses? - In the past ten years:
- Have you or any Affiliate been convicted of or pled guilty or nolo contendere
("no contest") in a U.S. federal, state, non-U.S. or military court to any felony?
(ii) Have you or any Affiliate been charged with any felony?
- Have you or any Affiliate been charged with a misdemeanor listed in Question 8(A) above?
If you answered "YES" to any item in this Part 8, please explain:
9. Regulatory Actions
- Has the U.S. Securities and Exchange Commission (SEC), the U.S. Commodity Futures Trading Commission (CFTC), FINRA or any other self-regulatory
organization or commodities exchange, any other federal regulatory agency, any | YES NO |
state regulatory agency, or any foreign financial regulatory authority ever: |
- Subjected you or any Affiliate to an investigation, hearing or Proceeding of any nature or kind?
- Found you or any Affiliate to have made a false statement or omission, or been dishonest, unfair or unethical?
- Found you or any Affiliate to have been involved in a violation of investment- related statutes or regulations?
- Found you or any Affiliate to have been a cause of an investment-related
business having its authorization to do business denied, suspended, revoked or restricted?
- Entered an Order against you or any Affiliate in connection with an investment- related activity?
- Imposed a civil money penalty on you or any Affiliate, or ordered you or any Affiliate to cease and desist from any activity?
- Denied, expelled, suspended, restricted or revoked your registration, license, membership or any Affiliate's registration, license or membership, or otherwise prevented you or any Affiliate, from associating with an investment-related business or restricted your activity or any Affiliate's activity?
OTC Markets Group Inc. | Page 5 of 9 |
Personal Information Form (v. 3.0 March 20, 2019) |
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Respiri Ltd. published this content on 15 July 2022 and is solely responsible for the information contained therein. Distributed by Public, unedited and unaltered, on 15 July 2022 05:03:02 UTC.