TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Debentures and Warrants Issuer: Grown Rogue International Inc. (the “Issuer”) SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. 6. For more information about this investment Paramount Gold Nevada Corp. 00 Xxxxxxxx Xxxxxx, Winnemucca, Nevada 89445 Attention: Xxxxx Xxxxxxx, Chief Financial Officer Phone: 000 000-0000 Email: xxxxx@xxxxxxxxxxxxxxx.xxx Website: xxx.xxxxxxxxxxxxxxx.xxx For more information about prospectus exemptions, contact your local securities regulator. You can find contact information at xxx.xxxxxxxxxx‑xxxxxxxxxxxxxx.xx. Signature of executive officer of the issuer (other than the purchaser): Date: (The Investor, contact person at the issuer and the issuer must receive a copy of the form signed by the Investor.) D-3 DM3\5243217.4 EXHIBIT “E” CONTACT INFORMATION Alberta Securities Commission Xxxxx 000, 000—0xx Xxxxxx XX Xxxxxxx, Xxxxxxx X0X 0X0 Telephone: (000) 000-0000 Toll free in Canada: 0-000-000-0000 Facsimile: (000) 000-0000 Public official contact regarding indirect collection of information: FOIP Coordinator British Columbia Securities Commission X.X. Xxx 00000, Xxxxxxx Xxxxxx 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 Inquiries: (000) 000-0000 Toll free in Canada: 1-800-373-6393 Facsimile: (000) 000-0000 Email: XXX-xxxxxxx@xxxx.xx.xx Public official contact regarding indirect collection of information: FOI Inquiries The Manitoba Securities Commission 000-000 Xx. Xxxx Xxxxxx Winnipeg, Manitoba R3C 4K5 Telephone: (000) 000-0000 Toll free in Manitoba: 0-000-000-0000 Facsimile: (000) 000-0000 Public official contact regarding indirect collection of information: Director Financial and Consumer Services Commission (New Brunswick) 00 Xxxxxxxxx Xxxxxx, Xxxxx 000 Xxxxx Xxxx, New Brunswick E2L 2J2 Telephone: (000) 000-0000 Toll free in Canada: 1-866-933-2222 Facsimile: (000) 000-0000 Email: xxxx@xxxx.xx Public official contact regarding indirect collection of information: Chief Executive Officer and Privacy Officer Government of Newfoundland and Labrador Financial Services Regulation Division X.X. Xxx 0000 Xxxxxxxxxxxxx Xxxxxxxx 0xx Xxxxx, Xxxx Xxxxx Xxxxxx Xxxxxx Drive St. John’s, Newfoundland and Labrador A1B 4J6 Attention: Director of Securities Telephone: (000) 000-0000 Facsimile: (000) 000-0000 Public official contact regarding indirect collection of information: Superintendent of Securities Government of the Northwest Territories Office of the Superintendent of Securities X.X. Xxx 0000 Xxxxxxxxxxx, Xxxxxxxxx Xxxxxxxxxxx X0X 0X0 Telephone: (000) 000-0000 Facsimile: (000) 000-0000 Public official contact regarding indirect collection of informati...
TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Units Issuer: Paramount Gold Nevada Corp. SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. OR SELLING SECURITY HOLDER
TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Shares of common stock of the Issuer (“Shares”) and warrants to purchase Shares Issuer: XxxXxx Pharmaceuticals, Inc. (the “Issuer”) Purchased from: the Issuer The SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. 6. For more information about this investment Chemesis International Inc. Xxxxx 0000, 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx, X0X 0X0 Attention: Xxxx Xxxxxx Email: xxxxxxxxxx@xxxxxxxx.xxx For more information about prospectus exemptions, contact your local securities regulator. You can find contact information at xxx.xxxxxxxxxx-xxxxxxxxxxxxxx.xx. Signature of executive officer of the issuer (other than the purchaser): Date: Form instructions: 1 This form does not mandate the use of a specific font size or style but the font must be legible.
TO BE COMPLETED BY THE ISSUER. 6. For more information about this investment Lexaria Corp. 950 – 0000 Xxxx Xxxxxx Xxxxxx Vancouver, BC Canada V6E 4A4 Attention: President Tel: 000.000.0000 Fax: 000.000.0000 For more information about prospectus exemptions, contact your local securities regulator. You can find contact information at xxx.xxxxxxxxxx-xxxxxxxxxxxxxx.xx. PROVISIONS APPLICABLE TO A UNITED STATES PURCHASER CERTIFICATION OF U.S. PURCHASER NOTE: the provisions on this page are applicable ONLY if the Purchaser is in the United States or is a “U.S. person” as defined in Regulation S under the United States Securities Act of 1933, as amended. (Capitalized terms not specifically defined in this Certification have the meaning ascribed to them in the Subscription Agreement to which this Schedule is attached.) In connection with the execution of the Subscription Agreement to which this Schedule is attached, the undersigned (the “Purchaser”) represents and warrants to the Issuer that:
TO BE COMPLETED BY THE ISSUER. 1. About Your Investment Type of securities: Class A or Class F Units (“Units”) Issuer: AGF SAF Private Credit Trust Purchased from: AGF SAF Private Credit Trust SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Units Issuer: Siyata Mobile Inc. (the “issuer”) SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. 6. For more information about this investment Tri City Group Monthly Income Mortgage Trust c/o Tri City Fund Management Ltd. 1000 – 000 Xxxx Xxxxxxxx Xxxxxx Xxxxxxxxx, XX X0X 0X0 Telephone: 000.000.0000 Email: xxxxxxxxxxxxx@xxxxxxxxxxxx.xx For more information about prospectus exemptions, contact your local securities regulator. You can find contact information at xxx.xxxxxxxxxx-xxxxxxxxxxxxxx.xx. Exhibit I to Schedule “C” SCHEDULE “D” ELIGIBLE INVESTOR QUESTIONNAIRE The purpose of this Questionnaire is to assure Tri City Group Monthly Income Mortgage Trust (the “Issuer”) that the undersigned (the “Purchaser”) will meet certain requirements for the registration and prospectus exemptions provided for under National Instrument 45-106 (“NI 45-106”), as adopted by the various provincial and territorial Securities Commissions in Canada, in respect of a proposed private placement of securities by the Issuer (the “Transaction”). The Issuer will rely on the information contained in this Questionnaire for the purposes of such determination. The undersigned Purchaser covenants, represents and warrants to the Issuer that the Purchaser satisfies one or more of the categories of “eligible investor” (as that term is defined in NI 45-106) indicated below (please check the appropriate box):
