Form 51-105F1 Notice – OTC Issuer Ceases to be an OTC Reporting Issuer This is the form required under paragraph 4(1)(d) of Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets for an OTC issuer to give notice that it has ceased to be an OTC reporting issuer under section 3 of the Instrument in a jurisdiction other than Québec. In Québec, an OTC reporting issuer must apply to the securities regulatory authority to have its status as an OTC reporting issuer revoked in order to cease to be a reporting issuer. The Issuer Name of Issuer: (the Issuer) Head office address: Last head office address (if different from above): Telephone number: Fax number: E-mail address: Ticker-symbol date: Ceasing to be a Reporting Issuer The Issuer certifies the following statements to be true: 1. The Issuer’s business is not directed or administered, and has not been directed or administered for at least one year, in or from [insert name of local jurisdiction]. 2. Promotional activities are not carried on, and have not been carried on for at least one year, in or from [insert name of local jurisdiction]. 3. More than one year has passed since the ticker-symbol date. If the preceding statements are true, on filing this Notice, the Issuer is no longer an OTC reporting issuer in [insert name of local jurisdiction]. If the preceding statements are true, on filing this Notice, the Issuer has ceased to be a reporting issuer in [name of local jurisdiction].
Certificate On behalf of the Issuer, I certify that the statements made in this Notice are true. Date: ____________________________ __________________________________ Name of Issuer __________________________________ Print name, title and telephone number of person signing on behalf of the Issuer __________________________________ Signature Warning: It is an offence to make a statement in this Notice that is false or misleading in a material respect, or to omit facts that make this Notice false or misleading in a material respect. 2
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