Form 11 - Application for exempt purchaser status [F - Rescinded]

This is the form required under section 88 of the Securities Rules for an application for exempt purchaser status under sections 45 (2) (4) and 74 (2) (3) of the Securities Act.

FORM 11

SECURITIES ACT

APPLICATION FOR EXEMPT PURCHASER STATUS

1. State the name, address for service and telephone number of the applicant.
   
   ______________________________________________________________
   
   ______________________________________________________________
   
2. State the jurisdiction and date of incorporation, organization or continuation of the applicant.
   
   ______________________________________________________________
   
   ______________________________________________________________
   
3. State the jurisdiction in which the applicant is authorized to carry on business as a financial institution, and provide a copy of the applicant's charter or license issued by the appropriate regulatory authority.
   
   ______________________________________________________________
   
   ______________________________________________________________
   
4. Name all persons that are insiders of the applicant, or that would be insiders of the applicant were it a reporting issuer under the British Columbia Securities Act, and state their relationship to the applicant.
   
   ______________________________________________________________
   
   ______________________________________________________________
   
5. Name all individuals who are officers, directors, trustees, partners or representatives, as the case may be, of the applicant, and state the occupations of each of them for the past five years.
   
   ______________________________________________________________
   
   ______________________________________________________________
   
6. State any other relevant facts and reasons why the applicant should be designated as an exempt purchaser.
   
   ______________________________________________________________
   
   ______________________________________________________________

If the space provided in any item is insufficient, additional pages may be used and must be cross referenced to the item, and signed by the applicant.

The undersigned hereby acknowledge that this application is true and accurate in all respects.

Dated at __________________________ this _______ day of ___________, 19____.
                       (insert city and country) 

_____________________________
(insert name of applicant)

_________________________________ ___________________________________
(signature of authorized signatory)                 (signature of authorized signatory)

_________________________________ ___________________________________
(name and official capacity)                              (name and official capacity)

IT IS AN OFFENCE FOR A PERSON TO MAKE A STATEMENT IN A DOCUMENT REQUIRED TO BE FILED OR FURNISHED UNDER THE SECURITIES ACT OR THE SECURITIES REGULATION THAT, AT THE TIME AND IN THE LIGHT OF THE CIRCUMSTANCES UNDER WHICH IT IS MADE, IS A MISREPRESENTATION. 

July 7, 1989