Form 4Z - Consent to a criminal records check [F - Rescinded]

This is a form required under section 20 (2) of the Securities Act.

FORM 4Z

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Freedom of Information and Protection of Privacy Act

The personal information requested on this form is collected under the authority of and used for the purpose of administering the Securities Act. Questions about the collection or use of this information can be directed to the Supervisor, Registration, British Columbia Securities Commission, 1100 - 865 Hornby Street, Vancouver, British Columbia, V6Z 2H4. Telephone (604) 660-4833. Toll Free within British Columbia 1-800-373-6393.

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INSTRUCTION

Individuals that carry on registrable activities for registered dealers, underwriters and advisers that have their principal place of business in Canada in a jurisdiction outside British Columbia, or that are members of an exchange or self regulatory body in Canada, may file a form corresponding to Form 4 that is not in the form specified by the Executive Director. That is, they may file a corresponding form required by the jurisdiction in which the dealer, underwriter or adviser carries on its principal business or by the exchange or self regulatory body of which the dealer, underwriter or adviser is a member. Where this is the case and the form does not include a declaration of consent to a criminal records check, the individual must also file a completed Form 4Z ("Consent to a Criminal Records Check"), signed by the individual and sworn before a commissioner of oaths.

APPLICANT: PROVIDE ALL INFORMATION AND DATE AND SIGN THIS ACKNOWLEDGMENT.

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SURNAME         GIVEN NAME(S)                MAIDEN NAME             SEX

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ADDRESS                                     BIRTHDATE (YY/MM/DD)              BIRTHPLACE

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IF FOREIGN BORN,                            DATE (YY/MM/DD)   HEIGHT   WEIGHT   HAIR EYES
INDICATE DATE OF ENTRY

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Have you ever been convicted under the law of any Province, State or Country from which you have not been pardoned?

No o Yes o     If yes, please submit full details of those offences covered by Part 15 of the
                         Uniform Form 4.

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"I, the undersigned applicant, consent to the information on my application for registration or approval, or renewal thereof, being used to conduct a suitability investigation, including a criminal records check, regarding my application. I understand that failure by me to accurately disclose information about my criminal history, if any, may constitute an offence under the provincial Securities Act or equivalent, or under the Criminal Code (Canada)."

Sworn before me _______________________________ ________________________________

(Commissioner of Oaths, etc.) (Signature of Applicant/Deponent)

at the city of _________________, province of ____________ this ___ day of ______________, _____

COMMISSION USE ONLY

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IS A FOREIGN ENQUIRY REQUESTED? FILE NUMBER_____________________________________________

No o Yes o submit foreign resident/business history on an attachment.

If the check performed by the Royal Canadian Mounted Police reveals a failure by the applicant to accurately disclose the applicant's criminal history, release of the applicant's criminal record is hereby requested for the purpose of conducting an investigation of an offence: such release being authorized by Section 8(2)(a) of the Privacy Act (Canada).

________________________________ Dated this _________ day of ____________, _______

Signature of Commission Official (DAY) (MONTH) (YEAR)

________________________________ Dated this _________ day of ____________, _______

Signature of Officer (DAY) (MONTH) (YEAR)