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

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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

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