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, Québec, Nova Scotia and Newfoundland. INSIDER REPORT 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 and use of this information, you (See instructions on the back of this report) 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 1. NAME OF THE REPORTING ISSUER (BLOCK LETTERS) BOX 3. NAME, ADDRESS AND TELEPHONE NUMBER OF THE INSIDER (BLOCK LETTERS) FAMILY NAME OR CORPORATE NAME GIVEN NAMES NO. STREET BOX 2. INSIDER DATA CITY RELATIONSHIP(S) TO REPORTING ISSUER PROV. DAY / MONTH / YEAR DATE OF LAST REPORT FILED BUSINESS TELEPHONE NUMBER OR CHANGE IN DAY / MONTH / YEAR _ IF INITIAL REPORT, RELATIONSHIP DATE ON WHICH YOU BUSINESS FAX NUMBER FROM LAST REPORT YES NO BECAME AN INSIDER _ BOX 5. INSIDER HOLDINGS AND CHANGES (IF INITIAL REPORT, COMPLETE SECTIONS A D E AND F ONLY. SEE ALSO INSTRUCTIONS TO BOX 5) C A B TRANSACTIONS DESIGNATION OF CLASS OF SECURITIES BALANCE OF CLASS OF SECURITIES DATE NATURE NUMBER/VALUE ON LAST REPORT ACQUIRED DAY / MONTH / YEAR 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 the time and in the light of the circumstances in which it is submitted, is misleading or untrue. CORRESPONDENCE ENGLISH FRENCH BOX 7. SIGNATURE NAME (BLOCK LETTERS) KEEP A COPY FOR YOUR FILE BCSC 55-102F6 Rev. 2001 / 6 / 25 VERSION FRANÇAISE DISPONIBLE SUR DEMANDE BOX 4. JURISDICTION(S) WHERE THE ISSUER IS A REPORTING ISSUER OR THE EQUIVALENT ALBERTA ONTARIO APT BRITISH COLUMBIA QUÉBEC MANITOBA SASKATCHEWAN POSTAL CODE NEWFOUNDLAND _ CHANGE IN NAME, NOVA SCOTIA ADDRESS OR _ TELEPHONE NUMBER FROM LAST REPORT YES NO D E F DIRECT/INDIRECT IDENTIFY THE REGISTERED NUMBER/VALUE UNIT PRICE/ $ US PRESENT BALANCE OWNERSHIP/ HOLDER WHERE OWNERSHIP OF CLASS OF CONTROL OR DISPOSED OF EXERCISE PRICE IS INDIRECT OR WHERE CONTROL OR SECURITIES HELD DIRECTION DIRECTION IS EXERCISED SIGNATURE DAY / MONTH / YEAR DATE OF THE REPORT
INSTRUCTIONS Insider Reports in English and French are available from Manitoba, Ontario and Québec. 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 New Brunswick, the Northwest Territories, Nunavut, Prince Edward Island or the Yukon. 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 the 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: Reporting 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 United States dollars, check the space under “$ US” Alberta Securities Commission Securities Commission of Newfoundland 4th Floor, 300 – 5th Avenue S.W. P.O. Box 8700, 2nd Floor West Block Calgary, AB T2P 3C4 Confederation Building Attention: Information Officer * St. John’s, NF A1B 4J6 Telephone: (403) 297-6454 Attention: Director of Securities * Fax: (403) 297-6156 Telephone: (709) 729-4189 Fax: (709) 729-6187 British Columbia Securities Commission PO Box 10142, Pacific Centre Nova Scotia Securities Commission 701 West Georgia Street 2nd Floor, Joseph Howe Building Vancouver BC V7Y 1L2 1690 Hollis Street, P.O. Box 458 Attention: Supervisor, Insider Reporting * Halifax, NS B3J 3J9 Telephone: (604) 899-6500 or Attention: FOI Officer * (800) 373-6393 (in BC) Telephone: (902) 424-7768 Fax: (604) 899-6550 Fax: (902) 424-4625 The Manitoba Securities Commission Ontario Securities Commission 1130 – 405 Broadway Suite 1903, Box 55, 20 Queen Street West Winnipeg, MB R3C 3L6 Toronto, ON M5H 3S8 Attention: Continuous Disclosure * Attention: FOI Coordinator * Telephone: (204) 945-2548 Telephone: (416) 593-8314 Fax: (204) 945-4508 Fax: (416) 593-3666 BCSC 55-102F6 (Reverse) Rev. 2001 / 6 / 25List 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 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 the nature of ownership 90 Other 97 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 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 filed 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. Commission des valeurs mobilières du Québec ** Stock Exchange Tower P.O. Box 246, 22nd Floor 800 Victoria Square Montreal, PQ H4Z 1G3 Attention: Responsable de l’accès à l’information * Telephone: (514) 940-2150 or (800) 361-5072 (in Québec) Fax: (514) 873-3120 Saskatchewan Securities Commission 800 – 1920 Broad Street Regina, SK S4P 3V7 Attention: Director * Telephone: (306) 787-5645 Fax: (306) 787-5899 * For questions about the collection and use of personal information. ** In Québec questions about the collection and use of personal information may also be addressed to the Commission d’accès à l’information du Québec (1-888-528-7741).
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.