Form 51-105F3B Personal Information Form and Authorization of Indirect Collection, Use and Disclosure of Personal Information This Personal Information Form and Authorization of Indirect Collection, Use and Disclosure of Personal Information must be completed and delivered to the securities regulatory authority by each individual who is required to do so under section 10 of Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets. If an individual has previously delivered either Form 51-105F3A Personal Information Form and Authorization of Indirect Collection, Use and Disclosure of Personal Information or a personal information form to the Toronto Stock Exchange or TSX Venture Exchange in connection with another OTC Reporting Issuer and the information has not changed, the individual may deliver this Form in satisfaction of the requirement in section 10 of Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets if the Certificate and Consent below is completed. The securities regulatory authority does not make any of the personal information provided in this Form public, unless required under freedom of information legislation. CERTIFICATE AND CONSENT I, hereby certify that: (Please Print – Name of Individual) (a) I delivered form 51-105F3A Personal Information Form and Authorization of Indirect Collection, Use and Disclosure of Personal Information on ________________________ (insert date) for _______________________ (insert name of issuer). I have read and understood the questions, cautions, acknowledgement and consent in that Form, and the answers I have given to the questions in that Form and in any attachments to it are true and correct, except where stated to be to the best of my knowledge, in which case I believe the answers to be true; (b) I have read and understand the attached Schedule 1; (c) I consent to the collection, use and disclosure of the information in this Form and to the collection, use and disclosure of further personal information in accordance with Schedule 1; and (d) I understand that I am delivering this Form to a securities regulatory authority, and it is an offence under securities legislation to provide false or misleading information to the securities regulatory authority. Date Signature of person named above Name(s) of OTC reporting issuer(s) for which this Form is delivered
Form 51-105F3B Personal Information Form and Authorization of Indirect Collection, Use and Disclosure of Personal Information Schedule 1 Collection of Personal Information The securities regulatory authorities listed in Schedule 2 are authorized, under securities legislation, to collect personal information. The securities r egulatory authorities do not make any of the information provided in this Form public, unless required under freedom of information legislation. By signing the Certificate and Consent in this Form, you are consenting to submitting your personal information in this Form (the “Information”) to the securities regulatory authorities and to the collection and use by the securities regulatory authorities of the Information, as well as any other information that may be necessary to administer securities legislation and assist in the administration of securities laws e lsewhere. This may include the collection of information from law enforcement a gencies, other gov ernment or non -governmental regulatory authorities, self-regulatory organizations, exchanges, and quotation and t rade r eporting systems i n order t o conduct background checks, verify the Information, perform investigations and conduct enforcement proceedings. Under Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets, you are required to deliver the Information to the securities regulatory authorities because you are a director, officer, promoter or control person of an OTC Reporting Issuer. Under freedom of information and protection of privacy legislation, you have a right to be informed of the existence of personal information about you that is kept by a securities regulatory authority, to request access t o t hat i nformation, a nd t o r equest t hat s uch i nformation be c orrected, s ubject t o a pplicable f reedom of information and protection of privacy legislation. By s igning t he C ertificate a nd C onsent i n t his Form, you a cknowledge that the securities regulatory a uthorities may disclose the Information they collect about you, as permitted by law, where i ts use and disclosure i s for the purposes described above. The securities regulatory authorities may use a third party to process the Information, but when that happens, t he t hird pa rty is obligated to comply w ith the limite d use r estrictions de scribed above an d federal and provincial privacy legislation. Warning: It i s a n of fence t o s ubmit i nformation t hat, i n a material respect, and a t t he t ime a nd i n t he l ight of t he circumstances in which it is submitted, is misleading or untrue. Questions If you ha ve a ny que stions a bout t he c ollection, us e a nd di sclosure of t he i nformation you pr ovide t o a s ecurities regulatory authority, you may contact the securities regulatory authority a t the address or telephone number l isted in Schedule 2. 2
Form 51-105F3B Personal Information Form and Authorization of Indirect Collection, Use and Disclosure of Personal Information Schedule 2 Securities Regulatory Authorities British Columbia Securities Commission P.O. Box 10142, Pacific Centre 701 West Georgia Street Vancouver, British Columbia V7Y 1L2 Telephone: 604-899-6500 Toll free in British Columbia and Alberta 1-800-373-6393 Facsimile: 604-899-6506 Alberta Securities Commission Suite 600, 250 – 5 th Street SW Calgary, Alberta T2P 3C4 Telephone: 403-297-6454 Facsimile: 403-297-6156 Saskatchewan Financial Services Commission Suite 601 - 1919 Saskatchewan Drive Regina, Saskatchewan S4P 4H2 Telephone: 306-787-5879 Facsimile: 306-787-5899 The Manitoba Securities Commission 500 – 400 St Mary Avenue Winnipeg, Manitoba R3C 4K5 Telephone: 204-945-2548 Toll free in Manitoba 1-800-655-5244 Facsimile: 204-945-0330 Autorité des marchés financiers 800, Square Victoria, 22 e étage C.P. 246, Tour de la Bourse Montréal, Québec H4Z 1G3 Telephone: 514-395-0337 or 1-877-525-0337 Facsimile: 514-873-6155 (For delivery purposes only) Facsimile: 514-864-6381 (For privacy requests only) New Brunswick Securities Commission 85 Charlotte Street, Suite 300 Saint John, New Brunswick E2L 2J2 Telephone: 506-658-3060 Toll Free in New Brunswick 1-866-933-2222 Facsimile: 506-658-3059 3
Nova Scotia Securities Commission Suite 400, 5251 Duke Street 1690 Hollis Street Halifax, Nova Scotia B3J 1P3 Telephone: 902-424-7768 Facsimile: 902-424-4625 Prince Edward Island Securities Office 95 Rochford Street, 4 th Floor Shaw Building P.O. Box 2000 Charlottetown, Prince Edward Island C1A 7N8 Telephone: 902-368-4569 Facsimile: 902-368-5283 Government of Newfoundland and Labrador Financial Services Regulation Division P.O. Box 8700 Confederation Building 2 nd Floor, West Block Prince Philip Drive St. John’s, NFLD A1B 4J6 Attention: Director of Securities Telephone: 709-729-4189 Facsimile: 709-729-6187 Government of Yukon Department of Community Services Corporate Affairs, Yukon Securities Office 307 Black Street, 1 st Floor PO Box 2703 (C-6) Whitehorse, Yukon Y1A 2C6 Telephone: 867-667-5466 Facsimile: 867-393-6251 Government of the Northwest Territories Government of the Northwest Territories Office of the Superintendent of Securities P.O. Box 1320 Yellowknife, NT X1A 2L9 Attention: Deputy Superintendent, Legal & Enforcement Telephone: 867-920-8984 Facsimile: 867-873-0243 Government of Nunavut Department of Justice Legal Registries Division P.O. Box 1000, Station 570 1 st Floor, Brown Building Iqaluit, Nunavut X0A 0H0 Telephone: 867-975-6590 Facsimile: 867-975-6594 4
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