ONTARIO SECURITIES COMMISSION FORM 41-501F2
COLLECTION OF PERSONAL INFORMATION

Under the Freedom Of Information and Protection of Privacy Act

1. Notification

The legal authority for the indirect collection is clause 61(2)(e) of the Securities Act, R.S.O. 1990, c.S.5 (the "Act").

The principal purpose for which the personal information is intended to be used is the fulfilment of the Director's obligations under clause 61(2)(e) of the Act.

Indirect Collection - The issuer confirms that the individuals listed in the attached schedule have been notified of the issuer's filing of information with respect to their residence address, birth date, citizenship or nationality required for the purposes of clause 61(2)(e) of the Act. The individuals have also been notified of the legal authority for the collection, the principal purpose for which the information is intended to be used and the title, business address and business telephone number of the public official who can answer questions concerning the collection.

2. Consent

The issuer of securities hereunder is authorized to consent on behalf of each individual referred to in the attached schedule and described in clause 61(2)(e) of the Act, and hereby so consents to the Ontario Securities Commission collecting such personal information about such individuals as may be necessary for the Director to discharge his/her obligations under clause 61(2)(e) of the Act.

3. The Public Official Who Can Answer Questions About the Collection is:

Intelligence Officer, Enforcement Branch

Ontario Securities Commission

18th Floor, 20 Queen Street West

Toronto, Ontario M5H 2S8

(416) 593-0681

[ISSUER]

Per:

Authorized Signature Date

Name

Title

(Please print here name of

individual whose signature appears

above in the official capacity)

[Name of Issuer]