Full name

INSTRUCTION: Name of firm or, if a sole proprietor, individual owner’s name. State the full name of the firm or individual.

Trade name (if applicable)

INSTRUCTION: Any related trade names

Street Address

INSTRUCTION: State the street office for the head office of the firm or proprietorship. Do not include a P.O. box or agent for service

Address line 1 Address line 2 Country Province City Postal code

Website address for firm

INSTRUCTION: State the website address for the firm. If there is no website address, state “not applicable”.

Telephone number

INSTRUCTION: Telephone number for firm or, if sole proprietor, individual. Telephone number should be numbers only with no spaces.

Responsible individual information

First name Middle name Last name

INSTRUCTION: Name of individual responsible for ensuring conditions to use this registration exemption are met. State the name of the individual who may be contacted with respect to any questions regarding the contents of this report. This individual should be a senior executive for the firm.

Telephone number

INSTRUCTION: Telephone number for responsible individual named above. Telephone number should be numbers only with no spaces.

Email

INSTRUCTION: Email address for responsible individual named above.

Does the firm also carry on business at other office locations? Yes No

Salesperson's names

Salesperson's Names

INSTRUCTION: Names of salespersons employed by the firm to sell securities.

Salesperson #1

First name Middle name Last name

Salesperson #2

First name Middle name Last name

Salesperson #3

First name Middle name Last name

Date

About the ASC

Complain or Report

Securities Law & Policy

Issuer Regulation

Innovation in Finance (Sandbox)

Registrant & Market Regulation

Investment Funds

Small Business

Enforcement

News & Publications

Northwestern Exemption (Information Report under Blanket Order 31-505)

Street Address

Responsible individual information

Salesperson's Names