THE MANITOBA SECURITIES COMMISSION MSC RULE 2012-13 (Section 149.1, The Securities Act)
MULTILATERAL INSTRUMENT 51-105 ISSUERS QUOTED IN THE U.S. OVER-THE-COUNTER MARKETS
TABLE OF CONTENTS PART TITLE PAGE PART 1 DEFINITIONS AND REPORTING ISSUER DESIGNATION AND 1 DETERMINATION 1. Definitions 1 2. National Instrument definitions apply 2 3. Reporting issuer designation and determination 2 4. Ceasing to be an OTC reporting issuer 2 PART 2 DISCLOSURE 3 5. Additional disclosure requirements 3 6. Timely disclosure obligations 3 7. Registration statement 3 8. Promotional activities 4 9. Technical reports – mineral properties 4 10. Personal information form and authorization 4 PART 3 RESALE OF PRIVATE PLACEMENT SECURITIES 4 11. Resale of seed stock 4 12. Legends on seed stock 5 13. Resale of private placement securities acquired after ticker- 5 symbol date 14. No other hold periods 6 PART 4 OTHER RESTRICTIONS 6 15. Securities for services 6 16. Take-over bid 7 17. Insider reports 7 PART 5 EXEMPTION 7 18. Exemption 7 PART 6 TRANSITION AND COMING INTO FORCE 7 19. Transition – financial disclosure for non-SEC filers 7 20. Transition – oil and gas disclosure 7 21. Coming into force 8
PART 1 – DEFINITIONS AND REPORTING ISSUER DESIGNATION AND DETERMINATION Definitions 1. In this Instrument
"OTC issuer" means an issuer (a) that has issued a class of securities that are OTC-quoted securities, and (b) that has not issued any class of securities that are listed or quoted on one or more of the following: (i) TSX Venture Exchange Inc.; (ii) TSX Inc.; (iii) Canadian National Stock Exchange; (iv) Alpha Exchange Inc.; (v) The New York Stock Exchange LLC; (vi) NYSE Amex LLC; (vii) The NASDAQ Stock Market LLC; "OTC-quoted securities" means a cl ass of s ecurities t hat ha s be en assigned a t icker s ymbol by the Financial Industry Regulatory Authority in the United States of America for use on any of the over-the-counter markets in the United States of America and includes a class of securities whose trades have been reported in the grey market;
"OTC reporting issuer" means an OTC issuer that is a reporting issuer; "promotional activities" means activities or communications, by or on behalf of an issuer, that promote or could reasonably be expected to promote the purchase or sale of securities of the issuer, but does not include any of the following
(a) the dissemination of information or preparation of records in the ordinary course of the business of the issuer
(i) to promote the sale of products or services of the issuer; (ii) to raise public awareness of the issuer; (b) activities or communications necessary to comply with the requirements of (i) the securities legislation of any jurisdiction of Canada; (ii) the securities laws of any foreign jurisdiction governing the issuer;
- 2 - (iii) any exchange or market on which the issuer’s securities trade; "ticker-symbol date" means the date that an OTC issuer is first assigned a ticker symbol for any class of its securities;
"trade", in Québec, for the purpose of this Instrument, refers to any of the following activities (a) the activities described in the definition of "dealer" in section 5 of the Securities Act (R.S.Q., c. V-1.1), including the following activities:
(i) the sale or disposition of a security by onerous title, whether the terms of payment be on margin, instalment or otherwise, but does not include a t ransfer or the giving in guarantee of securities in connection with a debt or the purchase of a security, except as provided in paragraph (b);
(ii) participation as a trader in any transaction in a security through the facilities of an exchange or a quotation and trade reporting system;
(iii) the receipt by a registrant of an order to buy or sell a security; (b) a transfer or the giving in guarantee of securities of an issuer from the holdings of a control person in connection with a debt.
National Instrument definitions apply 2. Terms used in this Instrument that are defined or interpreted in National Instrument 51-102 Continuous Disclosure Obligations have the same meaning in this Instrument.
Reporting issuer designation and determination 3. An O TC i ssuer i s a r eporting i ssuer unde r securities le gislation if one or m ore of t he following apply
(a) on or after July 31, 2012, its business has been directed or administered in or from the local jurisdiction; (b) on or after July 31, 2012, promotional activities have been carried on in or from the local jurisdiction; (c) the ticker-symbol date is on or after July 31, 2012, and, on or before the ticker-symbol date, the issuer distributed a s ecurity to a person resident in the loc al jurisdiction and that security is of the class of securities that became the issuer’s OTC-quoted securities.
Ceasing to be an OTC reporting issuer 4.(1) Except in Québec, an OTC issuer ceases to be a reporting issuer under section 3 if all of the following conditions are met
(a) its business is not directed or administered, and has not been directed or administered for at least one year, in or from the local jurisdiction;
(b) promotional activities are not carried on, and have not been carried on for at least one year, in or from the local jurisdiction;
(c) more than one year has passed since the ticker-symbol date; (d) it has filed Form 51-105F1 Notice – OTC Issuer Ceases to be an OTC Reporting Issuer.
- 3 - 4.(2) Except in Québec, if an OTC reporting issuer ceases to be an OTC issuer as a result of its securities being listed or quot ed on a n e xchange or a quotation and t rade r eporting system specified in the definition of "OTC i ssuer" in section 1, the OTC reporting i ssuer must f ile Form 51-105F4 Notice – Issuer Ceases to be an OTC Reporting Issuer at l east 10 da ys be fore i ts ne xt r equired f iling unde r s ecurities legislation in the local jurisdiction.
4.(3) 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 under section 3.
PART 2 – DISCLOSURE Additional disclosure requirements 5. In addition to all other provisions of securities legislation that apply to a reporting issuer and its insiders, an OTC reporting issuer must comply with the provisions of the following National Instruments
(a) National Instrument 13 -101 System for Electronic Document Analysis and Retrieval (SEDAR) tha t apply to an electronic filer, despite section 2.1 of that instrument;
(b) National Instrument 51-102 Continuous Disclosure Obligations that apply to a reporting issuer that is a venture issuer;
(c) Part 6 of N ational I nstrument 51 -102 Continuous Disclosure Obligations despite section 6.1 of t hat instrument;
(d) National I nstrument 52 -109 Certification of Disclosure in Issuers’ Annual and Interim Filings that apply to a reporting issuer that is a venture issuer;
(e) National Instrument 52-110 Audit Committees that apply to a reporting issuer that is a venture issuer; (f) National I nstrument 58 -101 Disclosure of Corporate Governance Practices that a pply t o a r eporting issuer that is a venture issuer.
Timely disclosure obligations 6.(1) Section 14.2 of N ational Instrument 71 -101 The Multijurisdictional Disclosure System and section 4.2 of National Instrument 71-102 Continuous Disclosure and Other Exemptions Relating to Foreign Issuers do not apply to an OTC reporting issuer.
6.(2) An OTC reporting issuer may file a copy of the Form 8-K Current Report that it files with the SEC to comply w ith its obligation in paragraph 7.1(1)(b) of N ational I nstrument 51 -102 Continuous Disclosure Obligations to file Form 51-102F3 Material Change Report.
Registration statement 7.(1) If a n OTC i ssuer be comes a re porting issuer on the ticker-symbol da te, the OTC reporting issuer must file, within 5 days of the date it became a reporting issuer, a copy of the most recent registration statement it filed with the SEC.
7.(2) The O TC r eporting issuer m ust f ile the r egistration statement in electronic f ormat unde r section 2.2 of National Instrument 13-101 System for Electronic Document Analysis and Retrieval (SEDAR).
- 4 - Promotional activities 8.(1) If a pe rson will c arry on promotional activities unde r an agreement, arrangement, commitment or understanding with an OTC reporting issuer, the OTC reporting issuer must file a notice in the form of Form 51-105F2 Notice of Promotional Activities naming the person and describing the activities and the relationship of t he OTC reporting issuer with the person, a nd t he pa rticulars of t heir agreement, arrangement, commitment or understanding with the OTC reporting issuer.
8.(2) The O TC r eporting i ssuer m ust f ile t he not ice unde r s ubsection (1) within one of t he following dates
(a) at least one day before the promotional activities commence; (b) if on the date the OTC issuer became an OTC reporting issuer promotional activities are being carried on, within 5 days of that date.
8.(3) The OTC reporting issuer must f ile the not ice in electronic f ormat in accordance w ith National Instrument 13-101 System for Electronic Document Analysis and Retrieval (SEDAR).
Technical reports – mineral properties 9. Section 4.1 of National Instrument 43-101 Standards of Disclosure for Mineral Projects does not apply to an OTC reporting issuer.
Personal information form and authorization 10.(1) Each director, officer, promoter and control person of an OTC reporting issuer must deliver to the s ecurities r egulatory a uthorities Form 51-105F3A Personal Information Form and Authorization of Indirect Collection, Use and Disclosure of Personal Information or Form 51-105F3B Personal Information Form and Authorization of Indirect Collection, Use and Disclosure of Personal Information within 10 days of the issuer becoming an OTC reporting issuer, except for a promoter of an OTC issuer that becomes an OTC reporting issuer more than 2 years after the ticker-symbol date.
10.1(2) Each person that becomes a director, officer, promoter or control person of an OTC reporting issuer must deliver to the securities regulatory authorities a personal information form referred to in subsection (1) within 10 days of becoming a director, officer, promoter or control person of an OTC reporting issuer.
10.1(3) If a promoter or control person i s not an individual, then each of its directors, officers and control pe rsons must deliver a personal information f orm referred to in subsection (1) to the s ecurities regulatory authorities within 10 days of the promoter or control person becoming a promoter or control person of an OTC reporting issuer.
PART 3 – RESALE OF PRIVATE PLACEMENT SECURITIES Resale of seed stock 11. After the ticker-symbol date, a person must not trade a security of an OTC reporting issuer that t he pe rson a cquired on or a fter July 3 1, 2012 and before t he t icker-symbol da te unl ess either of the following occurs
(a) the trade is in connection with one or more of the following (i) a take-over bid or an issuer bid in a jurisdiction of Canada;
- 5 - (ii) an amalgamation, merger, reorganization or arrangement that is under a statutory procedure or court order;
(iii) a dissolution or winding-up of the issuer that is under a statutory procedure or court order; (b) all of the following conditions are met (i) the certificate representing the security carries the legend, or the ownership statement issued under a direct registration system or other electronic book entry system relating to the security bears the legend restriction notation, set out in subsection 12(2);
(ii) the pe rson t rades the s ecurity through an investment dealer r egistered in a j urisdiction of Canada from an account at that investment dealer in the name of that person;
(iii) the investment dealer executes the trade through any of the over-the-counter markets in the United States of America.
Legends on seed stock 12.(1) As soon as practicable after the ticker-symbol date, an OTC reporting issuer must place (a) a legend on each certificate representing a security issued before the ticker-symbol date; and (b) a legend restriction notation on each ownership statement issued under a direct registration system or other electronic book entry system relating to a security issued before the ticker-symbol date.
12.(2) The legend and legend restriction notation must state the following Unless permitted under section 11 of Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets, the holder of this security must not trade the security in or from a jurisdiction of Canada unless
(a) the security holder trades the security through an investment dealer registered in a jurisdiction of Canada from an account at that dealer in the name of that security holder, and
(b) the dealer executes the trade through any of the over-the-counter markets in the United States of America.
Resale of private placement securities acquired after ticker-symbol date 13.(1) A person must not trade a security of an OTC reporting issuer that the person acquired under an exemption from the prospectus requirement after the ticker-symbol date unless the following conditions are satisfied
(a) unless the security was acquired under a director or employee stock option, a 4-month period has passed from one of the following
(i) the date the OTC reporting issuer distributed the security; (ii) the date a control person distributed the security; (b) if the person trading the security is a control person of the OTC reporting issuer, the person has held the security for at least 6 months;
- 6 - (c) the num ber of s ecurities t he pe rson pr oposes t o t rade, pl us t he num ber of s ecurities of the OTC reporting issuer of the same c lass that the person has t raded in the preceding 12-month period, does not exceed 5% of the OTC reporting issuer’s outstanding securities of the same class;
(d) the person trades the security through an investment dealer registered in a jurisdiction of Canada; (e) the i nvestment de aler exe cutes t he t rade t hrough any of the over-the-counter markets in the United States of America;
(f) there has been no unusual effort made to prepare the market or create a demand for the security; (g) no extraordinary commission or other consideration is paid to a person for the trade; (h) if the person trading the security is a n i nsider of t he O TC r eporting i ssuer, t he pe rson r easonably believes that the OTC reporting issuer is not in default of securities legislation; and
(i) the certificate representing the security bears a legend, or the ownership statement issued under a direct registration system or other electronic book e ntry system relating to the security bears a legend restriction notation, stating the following:
The holder of this security must not trade the security in or from a jurisdiction of Canada unless the conditions in section 13 of Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets are met.
13.(2) Despite subsection (1), a pe rson may trade a s ecurity of a n O TC r eporting i ssuer t hat t he person acquired under an exemption from the prospectus requirement if the trade is in connection with one or more of the following
(a) a take-over bid or an issuer bid in a jurisdiction of Canada; (b) an a malgamation, merger, r eorganization or a rrangement t hat i s under a statutory procedure or court order;
(c) a dissolution or winding-up of the issuer that is under a statutory procedure or court order. No other hold periods 14. Sections 2.3, 2.4, 2.5 and 2.6 of National Instrument 45-102 Resale of Securities do not apply to the first trade of a security of an OTC reporting issuer distributed under an exemption from the prospectus requirement.
PART 4 – OTHER RESTRICTIONS Securities for services 15. An OTC reporting issuer must not distribute a security to a director, officer, or consultant of the issuer for the provision of a service unless
(a) the consideration for the service is commercially reasonable; (b) in the case of a debt, the debt is a bona fide debt; and
- 7 - (c) the security is distributed for a price that is at least at its current market value. Take-over bid 16. Section 4.2 of Multilateral Instrument 62-104 Take-Over Bids and Issuer Bids does not apply to a take-over bid for an OTC reporting issuer for 2 years after the ticker-symbol date.
Insider reports 17. A person that is exempt or otherwise not required to file an insider report under U.S. federal securities law relating to insider reporting may not rely on the exemption from insider reporting under section 17.1 of National Instrument 71-101 The Multijurisdictional Disclosure System or section 4.12 of National Instrument 71-102 Continuous Disclosure and Other Exemptions Relating to Foreign Issuers.
PART 5 – EXEMPTION Exemption 18. The r egulator, except i n Québec, or s ecurities r egulatory a uthority m ay, unde r t he s tatute referred t o i n A ppendix B of N ational I nstrument 14 -101 Definitions opposite t he na me of t he local jurisdiction, grant an exemption from this Instrument.
PART 6 – TRANSITION AND COMING INTO FORCE Transition – financial disclosure for non-SEC filers 19. Except i n B ritish C olumbia, f or a n O TC r eporting i ssuer t hat doe s not ha ve a c lass of securities registered under section 12 of the 1934 Act and is not required to file reports under paragraph 15 (d) of t he 1934 A ct, t he r equirements of N ational I nstrument 51 -102 Continuous Disclosure Obligations and National Instrument 52-109 Certification of Disclosure in Issuers’ Annual and Interim Filings concerning the filing of
(a) annual financial statements, related MD&A and annual certificates appl y onl y t o financial y ears beginning on or after January 1, 2012;
(b) interim financial reports, related MD&A and interim certificates apply only to interim periods that (i) begin on or after January 1, 2012; and (ii) end after July 31, 2012; (c) AIFs apply only to financial years beginning on or after January 1, 2012. Transition – oil and gas disclosure 20. Except in British Columbia, for an OTC r eporting i ssuer, t he r equirement of N ational Instrument 51-101 Standards of Disclosure for Oil and Gas Activities concerning the filing of Form 51-101F1 Statement of Reserves Data and Other Oil and Gas Information applies only to financial years beginning on or after January 1, 2012.
- 8 - Coming into force 21.(1) This Instrument comes into force on July 31, 2012. 21.(2) Despite subsection (1), except in British Columbia, sections 5, 6, 7, and 8 come into force on September 30, 2012.
21.(3) This Instrument may be cited as MSC Rule 2012-13.
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.
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Form 51-105F2 Notice of Promotional Activities This is thfe form required under subsection 8(1) of Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets for an OTC reporting issuer to give notice of promotional activities.
Issuer Information Name of Issuer: (the Issuer) Head office address: __________________________________ __________________________________ Telephone number: __________________________________ Fax number: __________________________________ E-mail address: Notice of Promotional Activities 1. Identify each person engaged in promotional activities and provide the person’s address, telephone and fax number, and email address. If the person is not an individual, provide the name(s) of the individual(s) carrying on the activities.
__________________________________________________________________ __________________________________________________________________ 2. Describe the relationship between the Issuer and each person engaged in promotional activities.
__________________________________________________________________ __________________________________________________________________ 3. Include particulars of any agreement, arrangement, commitment or understanding between the Issuer and a person engaged in promotional activities. Include i. the effective date and duration of the agreement, arrangement or committment ii. the scope of activities being conducted, and iii. the compensation paid or to be paid by the Issuer, including any non-cash compensation
__________________________________________________________________ __________________________________________________________________ __________________________________________________________________
The Issuer [has / has not] issued a news release disclosing this information. If the Issuer has issued a news release, the Issuer may file it with this form.
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.
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Form 51-105F3A 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 i ndividual ha s previously d elivered a p ersonal i nformation f orm ( an “Exchange Form”) to the Toronto Stock Exchange or the TSX Venture Exchange and the information has not changed, the individual may deliver t he Exchange F orm i n l ieu of t his F orm if the Certificate an d Consent on pa ge 8 of t his F orm is completed an d at tached t o t he Exchange Form.
The securities regulatory authority does not make any of the personal information provided in this Form public, unless required under freedom of information legislation.
General Instructions: All Questions All questions must have a response. The response of “N/A” or “Not Applicable” for any questions, except Questions 1(B), 2B(iii) and 5, will not be accepted.
Questions 6 to 9 Please check (√) in the appropriate space provided. If your answer to an y of questions 6 t o 9 i s “YES”, you must, i n an at tachment, p rovide complete d etails, i ncluding t he ci rcumstances, r elevant d ates, n ames o f t he parties i nvolved a nd f inal di sposition, i f k nown. Any attachment must be initialled by the person completing this Form. Responses must consider all time periods.
Delivery The issuer must deliver completed Forms electronically via the System for Electronic Document Analysis and Retrieval (SEDAR) under the document type “Personal Information Form and Authorization”. Access to this document type is not available to the public.
CAUTION It is an offence to make a statement in this Form that is false or misleading in a material respect, or to omit facts that make this Form false or misleading in a material respect. Steps may be taken to verify the answers you have given in this Form, including verification of information relating to any previous criminal record.
DEFINITIONS “Offence” includes: (a) a summary conviction or indictable offence under the Criminal Code (Canada); (b) a quasi-criminal offence (for example under the Income Tax Act (Canada), the Immigration Act (Canada) or the tax, immigration, drugs, firearms, money laundering or securities legislation of any jurisdiction of Canada);
(c) a misdemeanour or felony under the criminal legislation of the United States of America, or any state or territory therein; or (d) an offence under the criminal legislation of any other foreign jurisdiction; NOTE: If you have received a pardon under the Criminal Records Act (Canada) for an Offence that relates to fraud (including any type of fraudulent activity), misappropriation of money or other property, theft, forgery, falsification of books or documents or similar Offences, you must disclose the pardoned offence in this Form. In such circumstances:
(a) the appropriate written response would be “Yes, pardon granted on (date)”; and (b) you must provide complete details in an attachment to this Form. “Proceedings” means: (a) a civil or criminal proceeding or inquiry before a court; (b) a proceeding before an arbitrator or umpire or a person or group of persons authorized by law to make an inquiry and take evidence under oath in the matter;
(c) a proceeding before a tribunal in the exercise of a statutory power of decision making where the tribunal is required by law to hold or afford the parties to the proceeding an opportunity for a hearing before making a decision; or
(d) a proceeding before a self-regulatory organization authorized by law to regulate the operations and the standards of practice and business conduct of its members and their representatives, in which the self-regulatory organization is required under its by-laws or rules to hold or afford the parties the opportunity for a hearing before making a decision, but does not apply to a proceeding in which one or more persons are required to make an investigation and to make a report, with or without recommendations, if the report is for the information or advice of the person to whom it is made and does not in any way bind or limit that person in any decision the person may have the power to make;
“securities regulatory authority” (or “SRA”) means a b ody created b y s tatute i n an y jurisdiction or i n a ny foreign ju risdiction t o administer s ecurities la w, r egulation and policy (e.g. securities commission) but does not include an exchange or other self r egulatory or professional organization;
“self-regulatory or professional organization” means: (a) a stock, commodities, futures or options exchange; (b) an association of investment, securities, mutual fund, commodities, or future dealers; (c) an association of investment counsel or portfolio managers; (d) an association of other professionals (e.g. legal, accounting, engineering); and (e) any ot her g roup, i nstitution or s elf-regulatory en tity, r ecognized b y a securities r egulatory a uthority, t hat i s r esponsible f or t he enforcement of r ules, di sciplines or c odes u nder a ny a pplicable l egislation, or c onsidered a s elf-regulatory or pr ofessional organization in another country.
1. A. IDENTIFICATION OF INDIVIDUAL COMPLETING FORM LAST NAME(S) FIRST NAME(S) MIDDLE NAME(S) (If none, please state)
NAME(S) MOST COMMONLY KNOWN BY: NAME OF ISSUER PRESENT or PROPOSED POSITION(S) IF DIRECTOR / OFFICER IF OFFICER – PROVIDE TITLE WITH THE ISSUER – check (√) all DISCLOSE THE DATE IF OTHER – PROVIDE DETAILS positions below that are applicable. ELECTED / APPOINTED (√) Month Day Year Director Officer Other
B. Other than the name given in Question 1A above, provide any legal names, assumed names, or nicknames, under which you have carried on business or have otherwise been known, including information regarding any name change(s) resulting from marriage, divorce, court order or any other process. Use an attachment if necessary. C. GENDER DATE OF BIRTH Month Day Year Male
Female
FROM TO MM YY MM YY PLACE OF BIRTH City Province/State Country
D. MARITAL STATUS FULL NAME OF SPOUSE – include common-law OCCUPATION OF SPOUSE E. TELEPHONE AND FACSIMILE NUMBERS AND E-MAIL ADDRESS RESIDENTIAL ( ) FACSIMILE ( ) BUSINESS ( ) E-MAIL F. RESIDENTIAL HISTORY – Provide all residential addresses for the past 10 YEARS starting with your current principal residential address. If you are unable to correctly identify the complete residential address for a period, which is beyond five years from the date of completion of this Form, the municipality and province or state and country must be identified. The regulator reserves the right to require the full address. STREET ADDRESS, CITY, PROVINCE/STATE, COUNTRY & POSTAL/ZIP CODE FROM TO MM YY MM YY 2. CITIZENSHIP A. CANADIAN CITIZENSHIP YES NO (i) Are you a Canadian Citizen? (ii) Are you a person lawfully in Canada as an immigrant but are not yet a Canadian citizen? (iii) If “Yes” to Question 2A(ii), the number of years of continuous residence in Canada: B. OTHER CITIZENSHIP YES NO (i) Do you hold citizenship in any country other than Canada? (ii) If “Yes” to Question 2B(i), the name of the country(s): (iii) Please provide U.S. Social Security number, where you have such a number 3. EMPLOYMENT HISTORY Provide your employment history for the 10 YEARS immediately prior to the date of this Form starting with your current employment. Use an attachment if necessary.
EMPLOYER NAME EMPLOYER ADDRESS POSITION HELD FROM TO MM YY MM YY 3
4. POSITIONS WITH OTHER ISSUERS YES NO A. While you were a director, officer or insider of an issuer, did any exchange or self-regulatory organization refuse approval for listing or quotation of that issuer (including a listing resulting from a qualifying transaction, reverse takeover, backdoor listing or change of business)? If yes, attach full particulars.
B. Has your employment in a sales, investment or advisory capacity with any firm or company engaged in the sale of real estate, insurance or mutual funds ever been terminated for cause?
C. Has a firm or company registered under the securities laws of any jurisdiction of Canada or of any foreign jurisdiction as a securities dealer, broker, investment advisor or underwriter, suspended or terminated your employment for cause?
D. Are you or have you during the last 10 years been a director, officer, promoter, insider or control person for any reporting issuer?
E. If “YES” to 4D above, provide the names of each reporting issuer. State the position(s) held and the period(s) during which you held the position(s). Use an attachment if necessary.
NAME OF REPORTING ISSUER POSITION(S) HELD 5. EDUCATIONAL HISTORY A. PROFESSIONAL DESIGNATION(S) – Provide any professional designation held and professional associations to which you belong. For example, Barrister & Solicitor, C.A., C.M.A., C.G.A., P.Eng., P.Geol., and CFA, etc. and indicate which organization and the date the designations were granted.
PROFESSIONAL DESIGNATION GRANTOR OF DESIGNATION DATE GRANTED ACTIVE? And MEMBERSHIP NUMBER And JURISDICTION OR FOREIGN JURISDICTION
MM DD YY YES NO B. Provide your post-secondary educational history starting with the most recent. SCHOOL LOCATION DEGREE OR DIPLOMA DATE OBTAINED MM DD YY 4
MARKET FROM TO TRADED ON MM YY MM YY
6. OFFENCES – If you answer “YES” to any item in Question 6, you must provide complete details in an attachment. YES NO A. Have you ever pleaded guilty to or been found guilty of an offence? B. Are you the subject of any current charge, indictment or proceeding for an offence? C. To the best of your knowledge, are you or have you ever been a director, officer, promoter, insider, or control person of an issuer, in any jurisdiction of Canada or in any foreign jurisdiction, at the time of events, where the issuer:
(i) has ever pleaded guilty to or been found guilty of an offence? (ii) is the subject of any current charge, indictment or proceeding for an offence? 7. BANKRUPTCY – If you answer “YES” to any item in Question 7, you must provide complete details in an attachment and attach a copy of any discharge, release or other applicable document.
YES NO A. Have you, in any jurisdiction of Canada or in any foreign jurisdiction, within the past 10 years had a petition in bankruptcy issued against you, made a voluntary assignment in bankruptcy, made a proposal under any bankruptcy or insolvency legislation, been subject to any proceeding, arrangement or compromise with creditors, or had a receiver, receiver-manager or trustee appointed to manage your assets?
B. Are you now an undischarged bankrupt? C. To the best of your knowledge, are you or have you ever been a director, officer, promoter, insider, or control person of an issuer, in any jurisdiction of Canada or in any foreign jurisdiction, at the time of events, or for a period of 12 months preceding the time of events, where the issuer:
(i) has made a petition in bankruptcy, a voluntary assignment in bankruptcy, a proposal under any bankruptcy or insolvency legislation, been subject to any proceeding, arrangement or compromise with creditors or had a receiver, receiver-manager or trustee appointed to manage the issuer’s assets?
(ii) is now an undischarged bankrupt? 8. PROCEEDINGS – If you answer “YES” to any item in Question 8, you must provide complete details in an attachment. YES NO A. CURRENT PROCEEDINGS BY SECURITIES REGULATORY AUTHORITY OR SELF-REGULATORY OR PROFESSIONAL ORGANIZATION Are you now, in any jurisdiction or in any foreign jurisdiction, the subject of:
(i) a notice of hearing or similar notice issued by a SRA? (ii) a proceeding or to your knowledge, under investigation, by an exchange or other self- regulatory or professional organization?
(iii) settlement discussions or negotiations for settlement with a SRA or any self-regulatory or professional organization?
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B. PRIOR PROCEEDINGS BY SECURITIES REGULATORY AUTHORITY OR SELF-REGULATORY OR PROFESSIONAL ORGANIZATION Have you ever:
(i) been reprimanded, suspended, fined, been the subject of an administrative penalty, or otherwise been the subject of any disciplinary proceedings, in any jurisdiction of Canada or in any foreign jurisdiction, by a SRA or self- regulatory or professional organization?
(ii) had a registration or licence for the trading of securities, exchange or commodity futures contracts, real estate, insurance or mutual fund products cancelled, refused, restricted or suspended?
(iii) been prohibited or disqualified under securities, corporate or any other legislation from acting as a director or officer of a reporting issuer?
(iv) had a cease trading or similar order issued against you or an order issued against you that denied you the right to use any statutory prospectus or registration exemption?
(v) been the subject of any other proceeding? C. SETTLEMENT AGREEMENT(S) Have you ever entered into a settlement agreement with a SRA, self-regulatory or professional organization, an attorney general or comparable official or body, in any jurisdiction of Canada or in any foreign jurisdiction, in a matter that involved, actual or alleged, fraud, theft, deceit, misrepresentation, conspiracy, breach of trust, breach of fiduciary duty, insider trading, unregistered trading in securities or exchange or commodity futures contracts, illegal distributions, failure to disclose material facts or changes or similar conduct, or any other settlement agreement with respect to any other violation of securities legislation in a jurisdiction or in a foreign jurisdiction or the rules of any self-regulatory or professional organization?
D. To the best of your knowledge, are you now or have you ever been a director, officer, promoter, insider, or control person of an issuer at the time of such event, in any jurisdiction of Canada or in any foreign jurisdiction, for which a securities regulatory authority or self-regulatory or professional organization has:
(i) refused, restricted, suspended or cancelled the registration or licensing of an issuer to trade securities, exchange or commodity futures contracts, or to sell or trade real estate, insurance or mutual fund products?
(ii) issued a cease trade or similar order or imposed an administrative penalty against the issuer, other than an order for failure to file financial statements that was revoked within 30 days of its issuance?
(iii) refused a receipt for a prospectus or other offering document, denied any application for listing or quotation or any other similar application, or issued an order that denied the issuer the right to use any statutory prospectus or registration exemptions?
(iv) issued a notice of hearing, notice as to a proceeding or similar notice against the issuer? (v) taken any other proceeding against the issuer, including a trading halt, suspension or delisting of the issuer (other than in the normal course for proper dissemination of information, pursuant to a reverse takeover, backdoor listing or similar transaction)?
(vi) entered into a settlement agreement with the issuer in a matter that involved actual or alleged fraud, theft, deceit, misrepresentation, conspiracy, breach of trust, breach of fiduciary duty, insider trading, unregistered trading in securities or exchange or commodity futures contracts, illegal distributions, failure to disclose material facts or changes or similar conduct by the issuer, or involved in any other violation of securities legislation in a jurisdiction or in a foreign jurisdiction or a self-regulatory or professional organization’s rules?
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YES NO
9. CIVIL PROCEEDINGS – If you answer “YES” to any item in Question 9, you must provide complete details in an attachment. YES NO A. JUDGMENT, GARNISHMENT AND INJUNCTIONS Has a court in any jurisdiction of Canada or in any foreign jurisdiction:
(i) rendered a judgment, ordered garnishment or issued an injunction or similar ban (whether by consent or otherwise) against you in a claim based in whole or in part on fraud, theft, deceit, misrepresentation, conspiracy, breach of trust, breach of fiduciary duty, insider trading, unregistered trading, illegal distributions, failure to disclose material facts or changes or allegations of similar conduct?
(ii) rendered a judgment, ordered garnishment or issued an injunction or similar ban (whether by consent or otherwise) against an issuer, for which you are currently or have ever been a director, officer, promoter, insider or control person, in a claim based in whole or in part on fraud, theft, deceit, misrepresentation, conspiracy, breach of trust, breach of fiduciary duty, insider trading, unregistered trading, illegal distributions, failure to disclose material facts or changes or allegations of similar conduct?
B. CURRENT CLAIMS (i) Are you now the subject, in any jurisdiction of Canada or in any foreign jurisdiction, of a claim that is based in whole or in part on actual or alleged fraud, theft, deceit, misrepresentation, conspiracy, breach of trust, breach of fiduciary duty, insider trading, unregistered trading, illegal distributions, failure to disclose material facts or changes or allegations of similar conduct?
(ii) To the best of your knowledge, are you currently or have you ever been a director, officer, promoter, insider or control person of an issuer now subject, in any jurisdiction of Canada or in any foreign jurisdiction, of a claim that is based in whole or in part on actual or alleged fraud, theft, deceit, misrepresentation, conspiracy, breach of trust, breach of fiduciary duty, insider trading, unregistered trading, illegal distributions, failure to disclose material facts or changes or allegations of similar conduct?
C. SETTLEMENT AGREEMENT (i) Have you ever entered into a settlement agreement, in any jurisdiction of Canada or in any foreign jurisdiction, in a civil action that involved actual or alleged fraud, theft, deceit, misrepresentation, conspiracy, breach of trust, breach of fiduciary duty, insider trading, unregistered trading, illegal distributions, failure to disclose material facts or changes or allegations of similar conduct?
(ii) To the best of your knowledge, are you currently or have you ever been a director, officer, promoter, insider or control person of an issuer that has entered into a settlement agreement, in any jurisdiction of Canada or in any foreign jurisdiction, in a civil action that involved actual or alleged fraud, theft, deceit, misrepresentation, conspiracy, breach of trust, breach of fiduciary duty, insider trading, unregistered trading, illegal distributions, failure to disclose material facts or changes or allegations of similar conduct?
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CERTIFICATE AND CONSENT I, hereby certify that: (Please Print – Name of Individual)
(a) I have read and understand the questions, cautions, acknowledgement and consent in this Form, and the answers I have given to the questions in this 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 Schedule 1; (c) I consent to the collection, use and disclosure of the information in this Form (or in a delivered Exchange Form if one is delivered in lieu of 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 with one or more securities regulatory authorities listed in Schedule 2 and it is an offence to make a statement in this Form that is false or misleading in a material respect, or to omit facts that make this Form false or misleading in a material respect.
Date Signature of person named above Name(s) of OTC reporting issuer(s) for which this form is delivered
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Form 51-105F3A Personal Information Form and Authorization of Indirect Collection, Use and Disclosure of Personal Information
Schedule 1 Collection of Personal Information The securities r egulatory a uthorities lis ted i n S chedule 2 are au thorized, u nder s ecurities l egislation, t o collect pe rsonal information. The securities r egulatory au thorities do not m ake a ny of t he i nformation provided i n this F orm public, u nless r equired under f reedom of information legislation.
By s igning th e Certificate an d Consent i n this F orm, you a re c onsenting t o s ubmitting y our pe rsonal i nformation i n this F orm (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 elsewhere. This may include the collection of information from law enforcement agencies, other government or non-governmental regulatory authorities, s elf-regulatory or ganizations, e xchanges, a nd q uotation a nd t rade r eporting s ystems in or der t o c onduct background c hecks, 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 r egulatory a uthorities because you ar e a d irector, o fficer, promoter or control person of an O TC 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 to that information, and to request that such information be corrected, subject to applicable freedom of information and protection of privacy legislation.
By signing the Certificate and Consent in this Form, you acknowledge that the securities regulatory authorities may disclose the Information they collect about you, as permitted by l aw, where i ts use and di sclosure i s for the purposes described above. T he securities r egulatory authorities may use a third party to process the Information, but when that happens, the third party is obligated to comply with the limited use restrictions described above and federal and provincial privacy legislation.
Warning: It is an offence to submit information that, in a material respect, and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue.
Questions If you have any questions about the collection, use and disclosure of the information you provide to a securities regulatory authority, you may contact the securities regulatory authority at the address or telephone number listed in Schedule 2.
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Form 51-105F3A 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 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
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
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Nova Scotia Securities Commission Suite 400, 5251 Duke 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 2nd 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
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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: I t 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.
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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
Nova Scotia Securities Commission Suite 400, 5251 Duke 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
Form 51-105F4 Notice – Issuer Ceases to be an OTC Reporting Issuer This is the form required under subsection 4(2) of Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets. This form must be completed and filed in jurisdictions other than Québec if an OTC reporting issuer has ceased to be an OTC issuer because it has a class of securities listed or quoted on an exchange or a quotation and trade reporting system specified in the definition of “OTC issuer” in section 1 of the Instrument.
In Québec, an OTC reporting issuer that has a class of securities listed or quoted on an exchange or a quotation and trade reporting system specified in the definition of “OTC issuer” in section 1 of the Instrument must apply to the securities regulatory authority to have its status as an OTC reporting issuer revoked in order to cease to be an OTC 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: Ceasing to be an OTC Reporting Issuer The Issuer’s _____________________[describe class of securities] are listed or quoted on ___________________________ [name of exchange or quotation and trade reporting system listed in definition of OTC issuer in section 1 of Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets].
If the Issuer has ceased to be an OTC issuer, the Issuer is no longer an OTC Reporting Issuer under Multilateral Instrument 51-105 Issuers Quoted in the U.S. Over-the-Counter Markets.
The Issuer [will not be / will remain] a reporting issuer in a jurisdiction of Canada.
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.
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