Secondary Shareholder Intake Form

First Name

Last Name

Preferred Email Address

Address

Investor Suitability

An individual who, either alone or with a spouse, beneficially owns financial assets having an aggregate realizable value that, before taxes but net of any related liabilities, exceeds $1,000,000, (Note: see definition of “financial assets*” below.)

An individual whose net income before taxes exceeded $200,000 in each of the two most recent calendar years or whose net income before taxes combined with that of a spouse exceeded $300,000 in each of the two most recent calendar years and who, in either case, reasonably expects to exceed that net income level in the current calendar year

An individual who, either alone or with a spouse, has net assets of at least $5,000,000

None of the options apply

(Note: the value of your personal residence cannot be included in the calculation of financial assets.)

(Note: financial assets include cash, securities, or a contract of insurance, a deposit or an evidence of a deposit.)

1. Does the shareholder wish to upload a void cheque to receive annual interest payments?

Yes

1a. Does the shareholder wish to have annual interest payment cheque mailed to the address provided above?

Yes

Preferred Mailing Address

2. Is the shareholder acting on instruction of a third party?

Yes

3. Is the shareholder a resident of Ontario?

Yes

4. Is the shareholder a resident of Saskatchewan?

Yes

5. Is the shareholder a US citizen for tax purposes?

Yes

6. How would the shareholder like to pay for their $600 share subscription?

Credit Card

E-Transfer

Government Issued Picture ID File Type

Image (e.g. JPG, PNG, GIF)

Document (e.g. PDF)

Government Issued Picture ID

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Supported File Types: JPG, PNG, GIF

Government Issued Picture ID

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Supported File Types: PDF

Void Cheque File Type

Image (e.g. JPG, PNG, GIF)

Document (e.g. PDF)

Void Cheque

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Supported File Types: JPG, PNG, GIF

Void Cheque

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Supported File Types: PDF