Personal Information Form And Authorization Of Indirect Collection, Use And Disclosure Of Personal Information (Page 2 of 4) in pdf

Form 51-105F3B

Personal Information Form

and Authorization of Indirect Collection,

Use and Disclosure of Personal Information

Schedule 1

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.

Questions

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.

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