Personal Information Form And Authorization Of Indirect Collection, Use And Disclosure Of Personal Information printable pdf download

Personal Information Form And Authorization Of Indirect Collection, Use And Disclosure Of Personal Information

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

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

Personal Information Form And Authorization Of Indirect Collection, Use And Disclosure Of Personal Information