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 individual has previously delivered a personal information form (an “Exchange Form”) to the Toronto Stock Exchange or the TSX Venture Exchange and the information has not changed, the individual may deliver the Exchange Form in lieu of this Form if the Certificate and Consent on page 8 of this Form is completed and attached to the 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.
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 any of questions 6 to 9 is “YES”, you must, in an attachment, provide complete details, including the circumstances, relevant dates, names of the parties involved and final disposition, if known. 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 Data Analysis and Retrieval + (SEDAR+) under the document type “Personal Information Form and Authorization”. Access to this document type is not available to the public.
“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;
(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. “Proceeding” 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;
(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 body created by statute in any jurisdiction or in any foreign jurisdiction to administer securities law, regulation and policy (e.g. securities commission) but does not include an exchange or other self regulatory 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);
(e) any other group, institution or self-regulatory entity, recognized by a securities regulatory authority, that is responsible for the enforcement of rules, disciplines or codes under any applicable legislation, or considered a self-regulatory or professional organization in another country.
1. A. IDENTIFICATION OF INDIVIDUAL COMPLETING FORM
LAST NAME(S) |
FIRST NAME(S) |
MIDDLE NAME(S) (If none, please state) |
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NAME(S) MOST COMMONLY KNOWN BY: |
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NAME OF ISSUER |
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PRESENT or PROPOSED POSITION(S) WITH THE ISSUER – check (√) all positions below that are applicable. |
(√) |
IF DIRECTOR / OFFICER DISCLOSE THE DATE ELECTED / APPOINTED |
IF OFFICER – PROVIDE TITLE IF OTHER – PROVIDE DETAILS |
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Year |
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Director |
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Officer |
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Other |
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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. |
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C. |
GENDER |
DATE OF BIRTH |
PLACE OF BIRTH |
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Province/State |
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Female |
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D. |
MARITAL STATUS |
FULL NAME OF SPOUSE – include common-law |
OCCUPATION OF SPOUSE |
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E. |
TELEPHONE AND FACSIMILE NUMBERS AND E-MAIL ADDRESS |
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RESIDENTIAL |
( ) |
FACSIMILE |
( ) |
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BUSINESS |
( ) |
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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. |
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STREET ADDRESS, CITY, PROVINCE/STATE, COUNTRY & POSTAL/ZIP CODE |
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2. CITIZENSHIP
A. |
CANADIAN CITIZENSHIP |
YES |
NO |
(i) Are you a Canadian Citizen? |
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(ii) Are you a person lawfully in Canada as an immigrant but are not yet a Canadian citizen? |
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(iii) If “Yes” to Question 2A(ii), the number of years of continuous residence in Canada: |
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B. |
OTHER CITIZENSHIP |
YES |
NO |
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(i) Do you hold citizenship in any country other than Canada? |
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(ii) If “Yes” to Question 2B(i), the name of the country(ies): |
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(iii) Please provide U.S. Social Security number, where you have such a number |
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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 |
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4. POSITIONS WITH OTHER ISSUERS
A. |
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YES |
NO |
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. |
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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? |
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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? |
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D. |
Are you or have you during the last 10 years been a director, officer, promoter, insider or control person for any reporting issuer? |
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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. |
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NAME OF |
POSITION(S) HELD |
MARKET |
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REPORTING ISSUER |
TRADED ON |
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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. |
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PROFESSIONAL DESIGNATION and MEMBERSHIP NUMBER |
GRANTOR OF DESIGNATION and JURISDICTION OR FOREIGN JURISDICTION |
DATE GRANTED |
ACTIVE? |
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YES |
NO |
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B. |
Provide your post-secondary educational history starting with the most recent. |
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SCHOOL |
LOCATION |
DEGREE OR DIPLOMA |
DATE OBTAINED |
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6. OFFENCES – If you answer “YES” to any item in Question 6, you must provide complete details in an attachment.
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YES |
NO |
Have you ever pleaded guilty to or been found guilty of an offence? |
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B. |
Are you the subject of any current charge, indictment or proceeding for an offence? |
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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: |
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(i) has ever pleaded guilty to or been found guilty of an offence? |
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(ii) is the subject of any current charge, indictment or proceeding for an offence? |
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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.
A. |
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YES |
NO |
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? |
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B. |
Are you now an undischarged bankrupt? |
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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: |
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(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? |
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(ii) is now an undischarged bankrupt? |
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8. PROCEEDINGS – If you answer “YES” to any item in Question 8, you must provide complete details in an attachment.
A. |
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YES |
NO |
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: |
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(i) a notice of hearing or similar notice issued by a SRA? |
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(ii) a proceeding or, to your knowledge, under investigation, by an exchange or other self- regulatory or professional organization? |
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(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: |
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(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? |
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(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? |
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(iii) been prohibited or disqualified under securities, corporate or any other legislation from acting as a director or officer of a reporting issuer? |
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(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? |
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(v) been the subject of any other proceeding? |
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C. |
SETTLEMENT AGREEMENT(S) |
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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? |
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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: |
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(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? |
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(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? |
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(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? |
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(iv) issued a notice of hearing, notice as to a proceeding or similar notice against the issuer? |
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(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)? |
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(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 of Canada or in a foreign jurisdiction or a self-regulatory or professional organization’s rules? |
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9. CIVIL PROCEEDINGS – If you answer “YES” to any item in Question 9, you must provide complete details in an attachment.
A. |
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YES |
NO |
JUDGMENT, GARNISHMENT AND INJUNCTIONS Has a court in any jurisdiction of Canada or in any foreign jurisdiction: |
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(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? |
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(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? |
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B. |
CURRENT CLAIMS |
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(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? |
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(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? |
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C. |
SETTLEMENT AGREEMENT |
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(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? |
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(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: |
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(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; |
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(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 |
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(d) I understand that I am delivering this Form to 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. |
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Date |
Signature of person named above |
Name(s) of OTC reporting issuer(s) for which this form is delivered |
Form 51-105F3A
Personal Information Form
and Authorization of Indirect Collection, Use and Disclosure of Personal Information
Collection of Personal Information
The securities regulatory authorities listed in Schedule 2 are authorized, under securities legislation, to collect personal information. The securities regulatory 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 elsewhere. This may include the collection of information from law enforcement agencies, other government or non-governmental regulatory authorities, self-regulatory organizations, exchanges, and quotation and trade reporting systems in order to 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 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 law, where its use and disclosure is for the purposes described above. The securities regulatory 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.
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.
and Authorization of Indirect Collection, Use and Disclosure of Personal Information
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
Nova Scotia Securities Commission
2 nd 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 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, 1st 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 1st Floor, Brown Building Iqaluit, Nunavut X0A 0H0 Telephone: 867-975-6590
Facsimile: 867-975-6594