54-101F4 - Omnibus Proxy (Proximate Intermediaries) [F]
NATIONAL INSTRUMENT 54-101
COMMUNICATION WITH BENEFICIAL OWNERS
OF SECURITIES OF A REPORTING ISSUER
OMNIBUS PROXY (PROXIMATE INTERMEDIARIES)
Note: Terms used in this Form have the meanings given to them in National Instrument 54-101.
The use of this Form is referenced in sections 1.1, 4.1 and 8.2 of National Instrument 54-101.
Subject to the paragraph that follows, [the undersigned], being a registered holder or proxy holder in respect of securities of the reporting issuer specified below, as at the beneficial ownership determination date, hereby appoints [insert names from reporting issuer's management proxy], with power of substitution, to attend, vote and otherwise act for and on behalf of [the undersigned] to the extent of the number of securities specified, in respect of all matters that may come before the meeting of securityholders described below, and at any adjournment or continuance.
The appointees shall not vote, or give a proxy requiring or authorizing another person or company to vote, the securities represented by this omnibus proxy except in accordance with voting instructions received from the beneficial owners whose securities are represented by this omnibus proxy or in accordance with other legal authority to vote the securities.
This instrument supersedes and revokes any prior appointment of proxy made by [the undersigned] with respect to the voting of the securities specified below at such meeting, or at any adjournment thereof.
Class/Series of Security:
Number of Securities:
Name of Registered Holder of Securities1
1[Instruction: Specify if securities are held through more than one registered holder, and specify the number of securities held through each registered holder.]:
Date of Meeting:
Beneficial Ownership Determination Date:
[Include date and signature]