IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions: Please provide the name of each trustee: Trustee Name: ________________________________________ Trustee Name: ________________________________________ Does the trust have assets greater than $5 million? Yes o No o Do you have such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of an investment in the Company? Yes o No o Indicate how often you invest in: Marketable Securities Often o Occasionally o Seldom o Never o Restricted Securities Often o Occasionally o Seldom o Never o Venture Capital Companies Often o Occasionally o Seldom o Never o The undersigned has been informed of the significance to the Company of the foregoing representations and answers contained in this Confidential Purchaser Questionnaire and such representations and answers have been provided with the understanding that the Company and the Selling Agent will rely on them. Individual Date: ________________________ _______________________________ Name of Individual (Please type or print) _______________________________ Signature of Individual _______________________________ Name of Joint Owner (Please type or print) _______________________________ Signature (Joint Owner) Partnership, Corporation or Other Entity Date: ________________________ _______________________________ Print or Type Entity Name By: Name:_______________________ Print or Type Name Title: ___________________________ _________________________________ Signature Title: ____________________________ _________________________________
IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions: Please provide the name of each trustee: Trustee Name: Trustee Name: Does the trust have assets greater than $5 million? YES NO Do you have such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of an investment in the Company? YES NO Indicate how often you invest in:
IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions: Please provide the name of each trustee: Trustee Name: ________________________________________ Trustee Name: ________________________________________ Does the trust have assets greater than $5 million? Yes ☐ No ☐ Do you have such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of an investment in the Company? Yes ☐ No ☐ Indicate how often you invest in: Marketable Securities Often ☐ Occasionally ☐ Seldom ☐ Never ☐ Restricted Securities Often ☐ Occasionally ☐ Seldom ☐ Never ☐ Venture Capital Companies Often ☐ Occasionally ☐ Seldom ☐ Never ☐
IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions: Please provide the name of each trustee: Trustee Name: ________________________________________ Trustee Name: ________________________________________ Does the trust have assets greater than $5 million? Yes [ ] No [ ] Do you have such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of an investment in the Company? Yes [ ] No [ ] Indicate how often you invest in: Marketable Securities Often [ ] Occasionally [ ] Seldom [ ] Never [ ] Restricted Securities Often [ ] Occasionally [ ] Seldom [ ] Never [ ] Venture Capital Companies Often [ ] Occasionally [ ] Seldom [ ] Never [ ] Annex B CANADIAN INVESTOR QUESTIONNAIRE (ALBERTA, BRITISH COLUMBIA, MANITOBA, NEWFOUNDLAND AND LABRADOR, NEW BRUNSWICK, NOVA SCOTIA, ONTARIO, XXXXXX XXXXXX ISLAND, QUEBEC, AND SASKATCHEWAN) TO: Anavex Life Sciences Corp. (the “Issuer”) RE: Purchase of Units (the “Units”) of the Issuer Capitalized terms used in this Questionnaire and not specifically defined have the meaning ascribed to them in the Private Placement Subscription Agreement between the Subscriber and the Issuer to which this Exhibit A is attached. In connection with the purchase by the Subscriber (being the undersigned, or if the undersigned is purchasing the Units as agent on behalf of a disclosed beneficial Subscriber, such beneficial Subscriber, shall be referred herein as the “Subscriber”) of the Units, the Subscriber hereby represents, warrants and certifies to the Issuer that the Subscriber:
IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions: Please provide the name of each trustee: Trustee Name: _____________________________________________________ Trustee Name: _____________________________________________________ Does the trust have assets greater than $5 million? Yes ☐ No ☐ Indicate how often you invest in: Marketable Securities Often ☐ Occasionally ☐ Seldom ☐ Never ☐ Restricted Securities Often ☐ Occasionally ☐ Seldom ☐ Never ☐ Venture Capital Companies Often ☐ Occasionally ☐ Seldom ☐ Never ☐ This completes the questions applicable to Trust Investors. Please sign below. The undersigned has been informed of the significance of the foregoing representations and answers contained in this Confidential Purchaser Questionnaire and such representations and answers have been provided with the understanding that the Company, will rely on them.
IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions about the trust and the trustee:
IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions: Please provide the name of each trustee: Trustee Name: ____________________________________________________________ Trustee Name: ___________________________________________________________
IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions: Please provide the name of each trustee: Trustee Name: Trustee Name: Does the trust have assets greater than $5 million? Yes □ No □ Do you have such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of an investment in the Company? Yes □ No □ Indicate how often you invest in: Marketable Securities Often □ Occasionally □ Seldom □ Never □ Restricted Securities Often □ Occasionally □ Seldom □ Never □ Venture Capital Companies Often □ Occasionally □ Seldom □ Never □ The undersigned has been informed of the significance to the Company of the foregoing representations and answers contained in this Confidential Purchaser Questionnaire and such representations and answers have been provided with the understanding that the Company and the Selling Agent will rely on them. Individual Date: Name of Individual (Please type or print) Signature of Individual Name of Joint Owner (Please type or print) Signature (Joint Owner) Partnership, Corporation or Other Entity Date: Print or Type Entity Name By: Name: Print or Type Name Title: Signature Title:
IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions: Please provide the name of each trustee: Trustee Name: _______________________________________________________________ Trustee Name: _______________________________________________________________ Does the trust have assets greater than $5 million? Yes ☐ No ☐ Indicate how often you invest in: Marketable Securities Often ☐ Occasionally ☐ Seldom ☐ Never ☐ Restricted Securities Often ☐ Occasionally ☐ Seldom ☐ Never ☐ Venture Capital Companies Often ☐ Occasionally ☐ Seldom ☐ Never ☐ This completes the questions applicable to Trust Investors. Please sign below. The undersigned has been informed of the significance of the foregoing representations and answers contained in this Confidential Purchaser Questionnaire and such representations and answers have been provided with the understanding that the Company, will rely on them. Individual By: Name of Individual (Please type or print) Signature of Individual Name of Joint Owner (Please type or print) Signature (Joint Owner) Partnership, Corporation or Other Entity By: Print or Type Entity Name By: Name Title: Signature (other authorized signatory, if any) DISCLOSURE SCHEDULES Schedule 5(e) No Violation or Conflict
IRREVOCABLE TRUSTS. If the trust is an irrevocable trust, please answer the following questions: Please provide the name of each trustee: Trustee Name: ________________________________________ Trustee Name: ________________________________________ Does the trust have assets greater than $5 million? Yes o No o Do you have such knowledge and experience in financial and business matters as to be capable of evaluating the merits and risks of an investment in the Company? Yes o No o Indicate how often you invest in: Marketable Securities Often o Occasionally o Seldom o Never o Restricted Securities Often o Occasionally o Seldom o Never o Venture Capital Companies Often o Occasionally o Seldom o Never o The undersigned has been informed of the significance to the Company of the foregoing representations and answers contained in this Confidential Purchaser Questionnaire and such representations and answers have been provided with the understanding that the Company and the Selling Agent will rely on them.
