Form 45-106F1
Report of Exempt Distribution
Except in British Columbia, this is the form required under section 6.1 of National Instrument 45-106 for a report of exempt distribution. In British Columbia, the required form is Form 45-106F6.
Issuer/underwriter information
Item 1: State the full name of the issuer of the security distributed and the address and telephone number of its head office. If the issuer of the security distributed is an investment fund, state the name of the fund as the issuer, and provide the full name of the manager of the investment fund and the address and telephone number of the head office of the manager. Include the former name of the issuer if its name has changed since last report. If an underwriter is completing this form, also state the full name of the underwriter and the address and telephone number of the head office of the underwriter.
Item 2: State whether the issuer is or is not a reporting issuer and, if reporting, each of the jurisdictions in which it is reporting.
Item 3: Indicate the industry of the issuer by checking the appropriate box next to one of the industries listed below.
Bio-tech Mining
Financial Services exploration/development
investment companies and funds production
mortgage investment companies Oil and gas
securitized products issuers Real estate
Forestry Utilities
Hi-tech Other (describe)
Industrial ______________________________
Details of distribution
Item 4: Complete Schedule I to this report. Schedule I is designed to assist in
completing the remainder of this report.
Item 5: State the distribution date. If the report
is being filed for securities distributed on more than one distribution date,
state all distribution dates.
Item 6: For each security distributed:
(a)
describe the type of
security,
(b)
state the total number
of securities distributed. If the security is convertible or exchangeable,
describe the type of underlying security, the terms of exercise or conversion
and any expiry date; and
(c)
state the exemption(s)
relied on.
Item 7: Complete the following table for each
Canadian and foreign jurisdiction where purchasers of the securities reside.
Do not include in this table, securities issued as payment for commissions or
finder’s fees disclosed under item 8, below.
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Each jurisdiction where purchasers reside |
Number of purchasers |
Price per security (Canadian $)1 |
Total dollar value raised from
purchasers in the jurisdiction |
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Total number of Purchasers |
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Total dollar value of distribution in all jurisdictions (Canadian $) |
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Note 1: If securities are issued at different prices list the highest and lowest price the securities were sold for.
Commissions and finder’s fees
Item 8: Complete the following table by providing information for each person who has received or will receive compensation in connection with the distribution(s). Compensation includes commissions, discounts or other fees or payments of a similar nature. Do not include payments for services incidental to the distribution, such as clerical, printing, legal or accounting services.
If the securities being issued as compensation are or include convertible securities, such as warrants or options, please add a footnote describing the terms of the convertible securities, including the term and exercise price. Do not include the exercise price of any convertible security in the total dollar value of the compensation unless the securities have been converted.
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Full name and address of the person being compensated |
Compensation paid or to be paid (cash and/or securities)
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Cash (Canadian $) |
Securities |
Total dollar value of compensation (Canadian $) |
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Number and type of securities issued |
Price per security |
Exemption relied on and date of distribution |
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Item 9: If a distribution is made in Ontario, please include the attached “Authorization of Indirect Collection of Personal Information for Distributions in Ontario”. The “Authorization of Indirect Collection of Personal Information for Distributions in Ontario” is only required to be filed with the Ontario Securities Commission.
Certificate
On behalf of the [issuer/underwriter], I certify that the statements made in this report are true.
Date:
Name of [issuer/underwriter] (please print)
Print name, title and telephone number of person signing
Signature
Instruction
The person filing the form must complete the bracketed information by deleting the inappropriate word.
Item 10: State the name, title and telephone number of the person who may be contacted with respect to any questions regarding the contents of this report, if different than the person signing the certificate.
IT IS AN OFFENCE TO MAKE A MISREPRESENTATION IN THIS REPORT.
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 or, where applicable, the regulators under the authority granted in securities legislation for the purposes of the administration and enforcement of the securities legislation.
If you have any questions about the collection and use of this information, contact the securities regulatory authority or, where applicable, the regulator in the jurisdiction(s) where the form is filed, at the address(es) listed at the end of this report.
Authorization of Indirect Collection of Personal Information for Distributions in Ontario
The attached Schedule I contains personal information of purchasers and details of the distribution(s). The issuer/underwriter hereby confirms that each purchaser listed in Schedule I of this report who is resident in Ontario
(a) has been notified by the issuer/underwriter
(i) of the delivery to the Ontario Securities Commission of the information pertaining to the person as set out in Schedule I,
(ii) that this information is being collected indirectly by the Ontario Securities Commission under the authority granted to it in securities legislation,
(iii) that this information is being collected for the purposes of the administration and enforcement of the securities legislation of Ontario, and
(iv) of the title, business address and business telephone number of the public official in Ontario, as set out in this report, who can answer questions about the Ontario Securities Commission’s indirect collection of the information, and
(b) has authorized the indirect collection of the information by the Ontario Securities Commission.
Schedule I
Complete the following table.
For reports filed under sub-section 6.1(1)(j) (TSX Venture Exchange offering) of National Instrument 45-106 the following table only needs to list the total number of purchasers by jurisdiction instead of including the name, residential address and telephone number of each purchaser.
Do not include in this table, securities issued as payment of commissions or finder’s fees disclosed under item 8 of this report.
The information in this schedule will not be placed on the public file of any securities regulatory authority or, where applicable, regulator. However, freedom of information legislation in certain jurisdictions may require the securities regulatory authority or, where applicable, regulator to make this information available if requested.
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Full name, residential address and telephone number of purchaser |
Number and type of securities purchased |
Total purchase price |
Exemption relied on |
Date of distribution |
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Instructions:
1. References to a purchaser in
this report are to the beneficial owner of the securities.
2. Except in British Columbia,
file this report and the applicable fee in each
jurisdiction in which a distribution is made at the addresses listed at the end
of this report. If the distribution is made in more than one jurisdiction, the
issuer/underwriter must complete a single report identifying all purchasers and
file that report in each of the jurisdictions in which the distribution is made.
Filing fees associated with the filing of the report are not affected by
identifying all purchasers in a single report.
2.1 In British Columbia, file Form
45-106F6 and pay the applicable fee. If the distribution is made in British
Columbia and one or more other jurisdictions, file Form 45-106F6 in British
Columbia and file this form, following instruction 2, in the other applicable
jurisdictions.
3. If the space provided for any
answer is insufficient, additional sheets may be used and must be cross-referenced
to the relevant part and properly identified and signed by the person whose
signature appears on the report.
4. One report may be used for
multiple distributions occurring within 10 days of each other provided that the
report is filed on or before the 10th day following the first of
such distributions.
5. The information in items 5, 6,
and 7 must reconcile with the information in Schedule I of Form 45-106F1. All
dollar amounts must be in Canadian dollars.
6. In order to determine the applicable
fee, consult the securities legislation of each jurisdiction in which a distribution is made.
7. This report must be filed in English or in French. In Québec, the issuer/underwriter must comply with linguistic obligations and rights prescribed by Québec law.
Securities Regulatory Authorities and Regulators
Alberta Securities Commission
Suite 600, 250–5th St. SW
Calgary, Alberta T2P 0R4
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
Ontario Securities Commission
Suite 1903, Box 55
20 Queen Street West
Toronto, Ontario M5H 3S8
Telephone: (416) 593- 8314
Toll free in Canada: 1-877-785-1555
Facsimile: (416) 593-8122
Public official contact regarding indirect collection of information:
Administrative Support Clerk
Telephone (416) 593-3684
Autorité des marchés financiers
800, Square Victoria, 22e 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 filing 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
Nova Scotia Securities Commission
2nd Floor, Joseph Howe Building
1690 Hollis Street
Halifax, Nova Scotia B3J 3J9
Telephone: (902) 424-7768
Facsimile: (902) 424-4625
Prince Edward Island Securities Office
95 Rochford Street, 4th 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
Attention: Director of Securities
Government of Yukon
Department of Community Services
Law Centre, 3rd Floor
2130 Second Avenue
Whitehorse, YT Y1A 5H6
Telephone: (867) 667-5314
Facsimile: (867) 393-6251
Government of 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
1st Floor, Brown Building
Iqaluit, Nunavut X0A 0H0
Telephone: (867) 975-6590
Facsimile: (867) 975-6594