12-602F - Application For Exempt Purchaser Status [BCF - Rescinded]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.

BC FORM 12-602F (Previously Form 11)

Securities Act

APPLICATION FOR EXEMPT PURCHASER STATUS

1. State the name, address for service and telephone number of the applicant.
   
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2. State the jurisdiction and date of incorporation, organization or continuation of the applicant.
   
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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.
   
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4. Name all persons that are insiders of the applicant, or that would be insiders of the applicant if it were a reporting issuer under the Securities Act (British Columbia), and state their relationships to the applicant.
   
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5. Name all individuals who are officers, directors, trustees, partners or representatives of the applicant and state the occupation of each of them for the past five years.
   
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6. State any other relevant facts and the reasons why the applicant should be designated as an exempt purchaser.
   
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The statements made in this application are true.

Dated at __________________________ on ____________.
                              (city and country)                               (date)

_____________________________
Name of applicant
(please print) 

_____________________________ ________________________
Signature of authorized signatory          Signature of authorized signatory

______________________________ ________________________
Name and title of authorized signatory   Name and title of authorized signatory
(please print)                                                (please print)

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

If the space provided for any answer is insufficient, additional sheets may be used. Each sheet must be cross referenced to the relevant section of the application and signed by the person who signs the application.