Government Organizations. [ ] (q) The government of Canada or of a Province of Canada, or any crown corporation or agency of a Canadian federal or provincial government; [ ] (r) Any municipality, public board or commission in Canada; [ ] (s) Any national, federal, state, provincial, territorial or municipal government of or in any foreign jurisdiction, or any agency of that government. Dated , . Signature of the Purchaser or authorized signatory of the Purchaser Name of Purchaser Address of Purchaser SCHEDULE B-2 BRITISH COLUMBIA & ALBERTA CONFIRMATION OF RELATIONSHIP (For Subscribers who are NOTan accredited investors but are Directors, Senior Officers, Control Persons and Founders and their Close Personal Friends, Close Business Associates and Relatives) The Subscriber represents and warrants to the Issuer that the Subscriber has read the following definitions from Multilateral Instrument 00-000 Xxxxxxx Raising Exemptions and certifies that the Subscriber has the relationship(s) to the Issuer or its directors, senior officers or control persons by virtue of the Subscriber being: (initial one or more as appropriate)
Government Organizations. [_] (p) the government of Canada or a province, or any crown corporation or agency of the government of Canada or a province. [_] (q) a municipality, public board or commission in Canada. [_] (r) any national, federal, state, provincial, territorial or municipal government of or in any foreign jurisdiction, or any agency of that government. Dated _________________, 2003. _________________________________________ Signature of the Subscriber or authorized signatory of the Subscriber _________________________________________ Name of Subscriber _________________________________________ Address of Subscriber
Government Organizations. Category 17 the government of Canada or a province, or any crown corporation or agency of the government of Canada or a province ____ Category 18 a municipality in Canada ____ Category 19 any national, federal, state, provincial, territorial or municipal government of or in any foreign jurisdiction, or any agency of that government OTHER CORPORATIONS, PARTNERSHIPS, TRUSTS & CHARITIES X Category 20 a registered charity under the INCOME TAX ACT (Canada) ---- ____ Category 21 a company, limited partnership, limited liability partnership, trust or estate, other than a mutual fund or non-redeemable investment fund, that had net assets of at least $5,000,000 as reflected in its most recently prepared financial statements ____ Category 22 a person or company in respect of which all of the owners of interests, direct or indirect, legal or beneficial, are persons or companies that are accredited investors The statements made in this Questionnaire are true and accurate to the best of my information and belief and I will promptly notify the Issuer of any changes in the answers. Dated: SEPTEMBER 18, 2003. X-------------------------------------------- Signature of individual (if Subscriber IS an individual) Maxwell Munday X-------------------------------------------- Authorized signatory (if Subscriber is NOT an individual) Maxwell-Munday & Gaylene-Association --------------------------------------------- Name of Subscriber (PLEASE PRINT) Maxwell Munday --------------------------------------------- Name of authorized signatory (PLEASE PRINT) Director --------------------------------------------- Official capacity of authorized signatory (PLEASE PRINT)
Government Organizations. [ ] (y) The government of Canada or of any jurisdiction, or any crown corporation, instrumentality or agency of a Canadian federal, provincial or territorial government; [ ] (z) Any Canadian municipality or any Canadian provincial or territorial capital city; [ ] (aa) Any national, federal, state, provincial, territorial or municipal government of or in any foreign jurisdiction, or any agency or instrumentality thereof; Dated ___________________, 20___ Signature of Investor or authorized signatory of the Investor Name of Investor Address of Investor SCHEDULE D CERTIFICATE OF U.S. INVESTOR This form must be completed by investors located inside the United States or U.S. Persons. A United States investor is any person in the United States or any U.S. Person. A U.S. Person includes, but is not limited to, (a) any natural person resident in the United States; (b) any partnership or corporation organized or incorporated under the laws of the United States; (c) any estate of which any executor or administrator is a U.S. Person; (d) any trust of which any trustee is a U.S. Person; (e) any agency or branch of a foreign entity located in the United States; (f) any non-discretionary account or similar account (other than an estate or trust) held by a dealer or other fiduciary for the benefit or account of a U.S. Person: (g) any discretionary account or similar account (other than an estate or trust) held by a dealer or other fiduciary organized, incorporated, or (if an individual) resident in the United States; and (h) any partnership or corporation organized outside the United States by a U.S. Person principally for the purpose of investing in securities not registered under the U.S. Securities Act of 1933, unless it is organized or incorporated, and owned, by U.S. Accredited Investors who are not natural persons, estates or trusts. The Investor covenants, represents and warrants to the “Issuer” that:
