OR1410 ― SHAREHOLDER DECLARATION

OR1410

SHAREHOLDER DECLARATION

(Section 2.4(2) of National Instrument

45-106 respecting the private issuer exemption)

OR1410-3 (CFPC/Corporate – 2007)

OR1410 ― SHAREHOLDER DECLARATION

...... (Corporate name)

SHAREHOLDER DECLARATION

(Section 2.4(2) of National Instrument 45-106 respecting the private issuer exemption)

I, the undersigned, hereby confirm that, when I became the holder of securities of...... (corporate name) on ...... , 20… (date securities acquired), I was an investor appearing among the categories of purchasers of securities identified below, of which I have checked the appropriate box:

  a) a director of the Corporation

  b) an employee of the Corporation

  c) a founder of the Corporation, participating in its operation

  d) a shareholder (shares or others) of the Corporation

e) a person participating in the controlling of the Corporation, meaning the sole possessor or with others (select one of the two options)

  - more than 20% of voting shares, or

  - a sufficient number of the Corporation’s shares to exert an important influence on its control

  f) the spouse

  the father or the mother

  the grandfather or the grandmother

  the brother or the sister

  the son or the daughter

of ...... , who, according to the case (select one of the two options)

  holds the following position in the Corporation , or

  is the spouse of ...... , who holds the following position in the Corporation: (select an option)

  administrator

  member of high management

  founder participating in the control of the Corporation

  a person participating in the control of the Corporation (in the sense of paragraph (e) mentioned above)

  g) (depending on the case:) a close friend (meaning really knowing this person personally and for a long time to be able to appreciate his capacities and his loyalty)

  (or:) a close partner (meaning having already had enough direct business relations with this person to be able to appreciate his qualities and his loyalty)

of ...... , who holds the following position in the Corporation (select an option)

  administrator

  member of high management

  founder participating in the control of the Corporation

  a person participating in the control of the Corporation (in the sense of paragraph (e) mentioned above)

  h) (Transfer only)

  the spouse

  the father or the mother

  the grandfather or the grandmother

  the brother or the sister

  the son of the daughter

(select one of the options)

  of the share holder and seller

  of ...... , spouse of the share holder and seller

  i) an «accredited investor», as defined by section 1.1 of National Instrument 45-106 of the Canadian Securities Administrators or provincial equivalent (hereinafter referred to as the “Regulation”) respecting prospectus and regulation exemptions

  j) a person (including a legal person, a partnership, an in trust corporation or an association) whose (select an option)

  administrators

  real owners of voting shares

are in majority the people aimed in the following paragraph(s) above:

a) /  / b) /  / c) /  / d) / 
e) /  / f) /  / g) /  / h) /  / i) / 

  k) an in trust corporation or a succession of which (select an option)

 all the beneficiaries

 the majority of the trustees or liquidators

are in majority the people aimed in the following paragraph(s) above:

a) /  / b) /  / c) /  / d) / 
e) /  / f) /  / g) /  / h) /  / i) / 

  l) a person who is not of the public for the following reasons:

In whereof I have signed, at ...... , dated ...... 20…

...... (name of shareholder)

...... (address)

SHARES SUBJECT TO THIS DECLARATION

OR1410-3 (CFPC/Corporate – 2007)