FORM 55-102F6 Notice – Collection and Use of Personal Information: The personal information required under this form is collected on behalf of and used by the securities regulatory authorities set out below for purposes of the administration and enforcement of certain provisions of the securities legislation in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Northwest Territories, Quebec, New Brunswick, Nova Scotia, INSIDER REPORT Prince Edward Island, []Newfoundland and Yukon. Some of the required information will be made public pursuant to the securities legislation in each of the jurisdictions indicated above. Other required information will remain confidential and will not be disclosed to any person or company except to any of the securities regulatory authorities or their authorized representatives. If you have any questions about the collection (See instructions on the back of this report) and use of this information, you may contact the securities regulatory authority in any jurisdiction(s) in which the required information is filed, at the address(es) or telephone number(s) set out on the back of this report. -BOX 3. NAME, ADDRESS AND TELEPHONE NUMBER OF THE INSIDER (BLOCK LETTERS) BOX 1. NAME OF THE REPORTING ISSUER (BLOCK LETTERS) FAMILY NAME OR CORPORATE NAME GIVEN NAMES NO. STREET CITY BOX 2. INSIDER DATA PROV RELATIONSHIP(S) TO REPORTING ISSUER DD MM YY DATE OF LAST BUSINESS TELEPHONE NUMBER REPORT FILED OR - - EXT CHANGE IN IF INITIAL REPORT, BUSINESS FAX NUMBER RELATIONSHIP DATE ON WHICH DD MM YY FROM LAST YES NO YOU BECAME AN REPORT INSIDER - - BOX 5. INSIDER HOLDINGS AND CHANGES (IF INITIAL REPORT, COMPLETE SECTIONS A D E AND F ONLY. SEE ALSO INSTRUCTIONS TO BOX 5) A B C TRANSACTIONS BALANCE OF DESIGNATION OF CLASS OF CLASS OF DATE NUMBER/VALUE SECURITIES SECURITIES ON NATURE ACQUIRED LAST REPORT DD MM YY BOX 6. REMARKS ATTACHMENT YES NO This form is used as a uniform report for the insider reporting requirements under all provincial securities Acts. The terminology used is generic to accommodate the various Acts. The undersigned certifies that the information given in this report is true and complete in every respect. It is an offence to submit information that, in a material respect and at CORRESPONDENCE ENGLISH FRENCH the time and in the light of the circumstances in which it is submitted, is misleading or untrue. BOX 7. SIGNATURE KEEP A COPY FOR YOUR FILE NAME (BLOCK LETTERS) BCSC 55-102F6 Rev. 2008 / 6 / 13 VERSION FRANCAISE DISPONIBLE SUR DEMANDE BOX 4. JURISDICTION(S) WHERE THE ISSUER IS A REPORTING ISSUER OR THE EQUIVALENT APT ALBERTA PRINCE EDWARD ISLAND BRITISH COLUMBIA NORTHWEST MANITOBA TERRITORIES POSTAL CODE NEW BRUNSWICK ONTARIO NEWFOUNDLAND QUÉBEC CHANGE IN NAME, ADDRESS OR NOVA SCOTIA SASKATCHEWAN TELEPHONE NUMBER FROM LAST REPORT YES NO YUKON D E F PRESENT DIRECT / IDENTIFY THE REGISTERED NUMBER/VALUE UNIT PRICE / BALANCE OF INDIRECT HOLDER WHERE OWNERSHIP DISPOSED OF EXERCISE PRICE $ US OWNDERSHIP / IS INDIRECT OR WHERE CLASS OF SECURITIES HELD CONTROL OR CONTROL OR DIRECTION IS DIRECTION EXERCISED SIGNATURE DD MM YY DATE OF THIS REPORT
INSTRUCTIONS Insider Reports in English and French are available from Manitoba, Ontario, Québec and New Brunswick. If you are a corporate insider in the province of Québec, you will receive correspondence in French. Individuals in the province of Québec will receive, upon request, correspondence in English. Where an insider of a reporting issuer does not own or have control or direction over securities of the reporting issuer, or where an insider’s ownership or direction or control over securities of the reporting issuer remains unchanged from the last report filed, a report is not required. Insider reports are not required to be filed in, Nunavut. If you have any questions about the form you should be using to file your report, see National Instrument 55-102 System for Electronic Disclosure by Insiders (SEDI). BOX 1 Name of reporting issuer Provide the full legal name of the reporting issuer. Use a separate report for each reporting issuer. BOX 2 Insider data Indicate all of your relationship(s) to the reporting issuer using the following codes: R eporting issuer that has acquired securities issued by itself 1 Subsidiary of the reporting issuer 2 Security holder who beneficially owns or who exercises control or direction over more than 10% of the securities of the reporting issuer (Québec Securities Act – 10% of a class of shares) to which are attached voting rights or an unlimited right to a share of the profits and to its assets in case of winding up 3 Director of a reporting issuer 4 Senior officer of a reporting issuer 5 Director or senior officer of a security holder referred to in 3 6 Director or senior officer of an insider or subsidiary of the reporting issuer, other than in 4, 5 and 6 7 Deemed insider – 6 months before becoming an insider 8 If you have filed a report before, indicate whether your relationship to the reporting issuer has changed. Specify the date of the last report you filed, and if it is an initial report, the date on which you became an insider. BOX 3 Name, address and telephone number of the insider Provide your name, address and business telephone number. BOX 4 Jurisdiction Indicate each jurisdiction where the issuer is a reporting issuer or the equivalent. BOX 5 Insider holdings and changes Show direct and indirect holdings separately, both in the initial report and where a transaction is reported. Indicate only one transaction per line. For an initial report complete only: A designation of class of securities held D present balance of class of securities held E nature of ownership (see List of Codes) F identification of the registered holder where ownership is not direct If you acquired or disposed of securities while an insider, complete sections A to F : A Indicate a designation of the securities traded that is sufficient to identify the class, including yield, series, maturity. B Indicate the number of securities, or for debt securities, the aggregate nominal value, of the class held, directly and indirectly, before the transaction that is being reported. C Indicate for each transaction: the date of the transaction (not the settlement date) the nature of the transaction (see List of Codes) the number of securities acquired or disposed of, or for debt securities, the aggregate nominal value the unit price paid or received on the day of the transaction, excluding the commission if the report is in American dollars, check the space under “$ US” List of Codes BOX 5 C Nature of transaction General Acquisition or disposition in the public market 10 Acquisition or disposition carried out privately 11 Acquisition or disposition under a prospectus 15 Acquisition or disposition under a prospectus exemption 16 Acquisition or disposition pursuant to a take-over bid, merger or acquisition 22 Acquisition or disposition under a purchase/ownership plan 30 Stock dividend 35 Conversion or exchange 36 Stock split or consolidation 37 Redemption/retraction/cancellation/repurchase 38 Short sale 40 Compensation for property 45 Compensation for services 46 Acquisition or disposition by gift 47 Acquisition by inheritance or disposition by bequest 48 Issuer Derivatives Grant of options 50 Exercise of options 51 Expiration of options 52 Grant of warrants 53 Exercise of warrants 54 Expiration of warrants 55 Grant of rights 56 Exercise of rights 57 Expiration of rights 58 Exercise for cash 59 Third Party Derivatives Acquisition or disposition (writing) of third party derivative 70 Exercise of third party derivative 71 Other settlement of third party derivative 72 Expiration of third party derivative 73 Miscellaneous Change in nature of ownership 90 Other 97 Correction of information 99 D Indicate the number of securities, or for debt securities, the aggregate nominal value, of the class held, directly and indirectly, after the transaction that is being reported. E Indicate the nature of ownership, control or direction of the class of securities held using the following codes: Direct ownership 1 Indirect ownership (identify the registered holder) 2 Control or direction (identify the registered holder) 3 F For securities that are indirectly held, or over which control or direction is exercised, identify the registered holder. BOX 6 Remarks Add any explanation necessary to make the report clearly understandable. If space provided for any item is insufficient, additional sheets may be used. Additional sheets must refer to the appropriate Box and must be properly identified and signed. Office staff are not permitted to alter a report. BOX 7 Signature and filing Sign and date the report. File one copy of each of the report in each jurisdiction in which the issuer is reporting within the time limits prescribed by the applicable laws of that jurisdiction. Manually sign the report. Legibly print or type the name of each individual signing the report. If the report is filed on behalf of a company, partnership, trust or other entity, legibly print or type the name of that entity after the signature. If the report is signed on behalf of an individual by an agent, there shall be filed with each jurisdiction in which the report is filed a duly completed power of attorney. If the report is filled by facsimile in accordance with National instrument 55-102 System for Electronic Disclosure by Insiders (SEDI), the report should be sent to the applicable securities regulatory authority at the fax number set out below.
Alberta Securities Commission Superintendent of Securities Autorite des marches financiers** Suite 600, 250 – 5 th Street SWCalgary, AB, T2P 0R4 Department of Justice Stock Exchange Tower Attention: Information Officer * Government of the Northwest Territories P.O. Box 246, 22nd Floor Telephone: (403) 297-6454 1st Floor, Stuart M. Hodgson Building 800 Victoria Square Facsimile: (403) 297-6156 5009-49th Street Montreal, PQ, H4Z 1G3 P.O. Box 1320 Attention: Responsable de l’accès à l’information British Columbia Securities Commission Yellowknife, Northwest Territories, X1A 2L9 Telephone: (514) 940-2150 or PO Box 10142, Pacific Centre Attention: Deputy Superintendent of Securities (800) 361-5072 (in Québec) 701 West Georgia Street Tel; (867) 920-3318 Facsimile: (514) 873-3120 Vancouver, BC, V7Y 1L2 Facsimile: (867) 873-0243 Attention: Supervisor, Insider Reporting * Saskatchewan Financial Services Commission Telephone: (604) 899-6500 or Nova Scotia Securities Commission Securities Division (800) 373-6393 (in BC) 2nd Floor, Joseph Howe Building 6 th Floor, 1919 Saskatchewan Drive Facsimile: (604) 899-6550 1690 Hollis Street, P.O. Box 458 Regina, SK, S4P 3V7 Halifax, NS, B3J 3J9 Attention: Director * The Manitoba Securities Commission Attention: FOI Officer * Telephone: (306) 787-5645 500 – 400 St. Mary Avenue Telephone: (902) 424-7768 Facsimile: (306) 787-5899 Winnipeg, MB, R3C 4K5 Facsimile: (902) 424-4625 Attention: Continuous Disclosure * New Brunswick Securities Commission Telephone: (204) 945-2548 Government of Nunavut 85 Charlotte Street, Suite 300 Facsmile (204) 945-4508 Legal Registries Division Saint John, NB, E2L 2J2 P.O. Box 100, Station 570 Attention: Corporate Finance Officer st Securities Commission of Newfoundland 1 Floor, Brown Building Telephone: (506) 658-3060 or P.O. Box 8700, 2nd Floor West Block Iqualuit, Nunavut, X0A 0H0 (866) 933-2222 (in New Brunswick) Confederation Building Contact person: Superintendent of Securities St. John’s, NFLD, A1B 4J6 Tel: (867) 975-6590 Superintendent of Securities Attention: Director of Securities * Fax: (867) 975-6595 Government of Prince Edward Island Telephone: (709) 729-4189 Email: legal.registries@gov.nu.ca 4th Floor, Shaw Building Facsimile: (709) 729-6187 95 Rochford Street Ontario Securities Commission P.O. Box 2000 Suite 1903, Box 55, 20 Queen Street West Charlottetown PE C1A 7N8 Toronto, ON, M5H 3S8 Tel: (902) 368-4550 Attention: FOI Coordinator * Telephone: (416) 593-8314 * For questions about the collection and use of Facsimile: (416) 593-3666 personal information Yukon Securities Office ** in Québec questions about the collection and use of Yukon Government personal information may also be addressed to the Law Centre, 3 rd Floor Commission d’accès à l’information du Québec 2130 Second Avenue (1-888-528-7741) (PO Box 2703) Whitehorse, YT Y1A 5H6 Attn: Superintendent of Securities Tel: (867) 667-5466 Fax: (867) 393-6251] BCSC 55-102F6 (Reverse) Rev. 2008 / 6 / 13 Note: The text of Form 6 reflects local amendments by made Yukon’s local Rule 11-803, PEI’s local Rule 55-802, Nunavut’s local Rule 11-801 and NWT’s local rule 11-801.
You are being directed to the most recent version of the statute which may not be the version considered at the time of the judgment.