Cibc Investor Services General Power Of Attorney Form (Page 5 of 6) in pdf

Cibc Investor Services General Power Of Attorney Form Page 5

6721-2016/03

Page 5 of 6

Account No.

CIBC Investor Services Inc. General Power of Attorney

Attorney Information

Legal Name of Attorney

Date of Birth (mm/dd/yyyy)

Primary Telephone No.

Address

City

Province/Foreign Info

Country

Postal Code

Employment Information

Employer’s Name

Address

City

Province/Foreign Info

Country

Type of Business

Occupation

Are you, your spouse, any person(s) living in the same home, trading authority, or anyone who exercises influence on this

Yes

account an Investment Industry Professional?

Are you an insider of a reporting issuer or any other issuer whose securities are publicly traded?

Yes

If Yes, list below

Do you alone or as part of a group hold more than 20% or have a control block of a reporting issuer or any other issuer

Yes

whose securities are publicly traded?

If Yes, list below

Primary Financial Institution -

Required only if the Attorney's identification was not verified at the Banking Centre.

Financial Institution

Bank Transit

Bank Account No.

Financial Institution Contact Name

Cibc Investor Services General Power Of Attorney Form Page 5