Form 55-102F6 Insider Report

Form-55-102F6 Insider Report

FORM 55-102F6
INSIDER REPORT
(See instructions on the back of this report)
Notice – Collection and Use of Personal Information: The personal information required under this form is collected on behalf of and used by the securities regulatory authorities set out below for purposes of the administration and enforcement of certain provisions of the securities legislation in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Northwest Territories, Quebec, New Brunswick, Nova Scotia, Prince Edward Island, []Newfoundland and Yukon. Some of the required information will be made public pursuant to the securities legislation in each of the jurisdictions indicated above. Other required information will remain confidential and will not be disclosed to any person or company except to any of the securities regulatory authorities or their authorized representatives. If you have any questions about the collection and use of this information, you may contact the securities regulatory authority in any jurisdiction(s) in which the required information is filed, at the address(es) or telephone number(s) set out on the back of this report.
BOX 1. NAME OF THE REPORTING ISSUER (BLOCK LETTERS)   BOX 3. NAME, ADDRESS AND TELEPHONE NUMBER OF THE INSIDER (BLOCK LETTERS)   BOX 4. JURISDICTION(S) WHERE
ISSUER IS A REPORTING ISSUER
OR THE EQUIVALENT
    FAMILY NAME OR CORPORATE NAME  
    GIVEN NAMES  
▢ ALBERTA ▢ PRINCE EDWARD ISLAND
▢ BRITISH COLUMBIA ▢ NORTHWEST TERRITORIES
▢ MANITOBA ▢ ONTARIO
▢ NEW BRUNSWICK ▢ QUÉBEC
▢ NEWFOUNDLAND ▢ SASKATCHEWAN
▢ NOVA SCOTIA ▢ YUKON
    NO.       STREET                     APT  
    CITY  
BOX 2. INSIDER DATA   PROV                           Postal Code  
RELATIONSHIP(S) TO REPORTING ISSUER   DD MM YY
          DATE OF LAST REPORT FILED      
  BUSINESS TELEPHONE NUMBER –                –         EXT  
CHANGE IN RELATIONSHIP FROM LAST REPORT▢  YES ▢ NO OR
IF INITIAL REPORT,
DATE ON WHICH YOU BECAME AN INSIDER
DD MM YY
     
  BUSINESS FAX NUMBER –     –  

BOX 5. INSIDER HOLDINGS AND CHANGES (IF INITIAL REPORT, COMPLETE SECTIONS A D E AND F ONLY. SEE ALSO INSTRUCTIONS TO BOX 5)

A B C
TRANSACTIONS
D E F
DESIGNATION OF CLASS OF SECURITIES BALANCE OF CLASS OF SECURITIES ON LAST REPORT Date Nature NUMBER/VALUE ACQUIRED NUMBER/VALUE DISPOSED OF UNIT PRICE / EXERCISE PRICE $US PRESENT BALANCE OF CLASS OF SECURITIES HELD DIRECT/INDIRECT OWNDERSHIP / CONTROL OR DIRECTION IDENTIFY THE REGISTERED HOLDER WHERE OWNERSHIP IS INDIRECT OR WHERE CONTROL OR DIRECTION IS EXERCISED
DD MM YY
                       
                       
                       
                       
                       
                       
                       
                       
                       
  BOX 6. REMARKS
ATTACHMENT      ▢ YES    ▢ NO   
This form is used as a uniform report for the insider reporting
requirements under all provincial securities Acts. The terminology
used is generic to accommodate the various Acts.
CORRESPONDENCE  ▢ ENGLISH   ▢FRENCH The undersigned certifies that the information given in this report is true and complete in every respect. It is an offence to submit information that, in a material respect and at the time and in the light of the circumstances in which it is submitted, is misleading or untrue.
KEEP A COPY FOR YOUR FILE BOX 7. SIGNATURE
BCSC 55-102F6 Rev. 2008 / 6 / 13 VERSION FRANCAISE DISPONIBLE SUR DEMANDE
NAME (BLOCK LETTERS) SIGNATURE   DD MM YY
    DATE OF THIS REPORT      

INSTRUCTIONS

Insider Reports in English and French are available from Manitoba, Ontario, Québec and New Brunswick. If you are a corporate insider in the province of Québec, you will receive correspondence in French. Individuals in the province of Québec will receive, upon request, correspondence in English.

Where an insider of a reporting issuer does not own or have control or direction over securities of the reporting issuer, or where an insider’s ownership or direction or control over securities of the reporting issuer remains unchanged from the last report filed, a report is not required. Insider reports are not required to be filed in, Nunavut.

If you have any questions about the form you should be using to file your report, see National Instrument 55-102 System for Electronic Disclosure by Insiders (SEDI).

BOX 1 Name of reporting issuer

Provide the full legal name of the reporting issuer. Use a separate report for each reporting issuer.

BOX 2 Insider data

Indicate all of your relationship(s) to the reporting issuer using the following codes:
Reporting issuer that has acquired securities issued by itself                         1
Subsidiary of the reporting issuer                                                                   2
Security holder who beneficially owns or who exercises control or direction over more than 10% of the securities of the reporting issuer (Québec Securities Act – 10% of a class of shares) to which are attached voting rights or an unlimited right
to a share of the profits and to its assets in case of winding up                     3
Director of a reporting issuer                                                                          4
Senior officer of a reporting issuer                                                                 5
Director or senior officer of a security holder referred to in 3                        6
Director or senior officer of an insider or subsidiary of the reporting issuer,
other than in 4, 5 and 6                                                                                   7
Deemed insider – 6 months before becoming an insider                               8
If you have filed a report before, indicate whether your relationship to the reporting issuer has changed.

Specify the date of the last report you filed, and if it is an initial report, the date on which you became an insider.

BOX 3 Name, address and telephone number of the insider

Provide your name, address and business telephone number.

BOX 4 Jurisdiction

Indicate each jurisdiction where the issuer is a reporting issuer or the equivalent.

BOX 5 Insider holdings and changes

Show direct and indirect holdings separately, both in the initial report and where a transaction is reported. Indicate only one transaction per line.

For an initial report complete only:
A designation of class of securities held
D present balance of class of securities held
E nature of ownership (see List of Codes)
F identification of the registered holder where ownership is not direct
If you acquired or disposed of securities while an insider, complete sections A to F :
A Indicate a designation of the securities traded that is sufficient to identify the class, including yield,
series, maturity.
B Indicate the number of securities, or for debt securities, the aggregate nominal value, of the class held, directly and indirectly, before the transaction that is being reported.
C Indicate for each transaction:

  • the date of the transaction (not the settlement date)
  • the nature of the transaction (see List of Codes)
  • the number of securities acquired or disposed of, or for debt securities, the aggregate nominal value
  • the unit price paid or received on the day of the transaction, excluding the commission
  • if the report is in American dollars, check the space under “$ US”

List of Codes

BOX 5 C Nature of transaction
General
Acquisition or disposition in the public market                                                         10
Acquisition or disposition carried out privately                                                         11
Acquisition or disposition under a prospectus                                                          15
Acquisition or disposition under a prospectus exemption                                        16
Acquisition or disposition pursuant to a take-over bid, merger or acquisition        22 Acquisition or disposition under a purchase/ownership plan                                   30
Stock dividend                                                                                                           35
Conversion or exchange                                                                                            36
Stock split or consolidation                                                                                       37
Redemption/retraction/cancellation/repurchase                                                      38
Short sale                                                                                                                   40
Compensation for property                                                                                       45
Compensation for services                                                                                        46
Acquisition or disposition by gift                                                                              47
Acquisition by inheritance or disposition by bequest                                               48
Issuer Derivatives
Grant of options                                                                                                        50
Exercise of options                                                                                                    51
Expiration of options                                                                                                 52
Grant of warrants                                                                                                       53
Exercise of warrants                                                                                                   54
Expiration of warrants                                                                                                55
Grant of rights                                                                                                           56
Exercise of rights                                                                                                       57
Expiration of rights                                                                                                    58
Exercise for cash                                                                                                        59
Third Party Derivatives
Acquisition or disposition (writing) of third party derivative                                     70
Exercise of third party derivative                                                                               71
Other settlement of third party derivative                                                                 72
Expiration of third party derivative                                                                            73
Miscellaneous
Change in nature of ownership                                                                                 90
Other                                                                                                                         97
Correction of information                                                                                          99
D Indicate the number of securities, or for debt securities, the aggregate nominal value, of the
class held, directly and indirectly, after the transaction that is being reported.
E Indicate the nature of ownership, control or direction of the class of securities held using
the following codes:
Direct ownership 1
Indirect ownership (identify the registered holder) 2
Control or direction (identify the registered holder) 3
F For securities that are indirectly held, or over which control or direction is exercised, identify
the registered holder.
BOX 6 Remarks

Add any explanation necessary to make the report clearly understandable.
If space provided for any item is insufficient, additional sheets may be used.
Additional sheets must refer to the appropriate Box and must be properly identified and signed.
Office staff are not permitted to alter a report.

BOX 7 Signature and filing

Sign and date the report.
File one copy of each of the report in each jurisdiction in which the issuer is reporting within the time limits prescribed by the applicable laws of that jurisdiction.
Manually sign the report.
Legibly print or type the name of each individual signing the report.
If the report is filed on behalf of a company, partnership, trust or other entity, legibly print or type the name of that entity after the signature.
If the report is signed on behalf of an individual by an agent, there shall be filed with each
jurisdiction in which the report is filed a duly completed power of attorney.
If the report is filled by facsimile in accordance with National instrument 55-102 System for Electronic Disclosure by Insiders (SEDI), the report should be sent to the applicable securities regulatory authority at the fax number set out below.