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ONTARIO SECURITIES COMMISSION FORM 41-501F4
NON-ISSUER FORM OF SUBMISSION TO
JURISDICTION
AND APPOINTMENT OF AGENT FOR SERVICE OF PROCESS
1. Name of issuer (the "Issuer"):
2. Jurisdiction of incorporation of Issuer:
3. Address of principal place of business of Issuer:
4. Description of securities (the "Securities"):
5. Date of prospectus (the "Prospectus") under which the Securities are offered:
6. Name of person filing this form (the "Filing Person") and Filing Person's relationship to
Issuer:
7. Jurisdiction of incorporation of Filing Person, if applicable, or jurisdiction of residence of
Filing Person:
8. Address of principal place of business of Filing Person:
9. Name of agent for service of process (the "Agent"):
10. Address for service of process of Agent in Canada (which address may be anywhere in
Canada):
11. The Filing Person designates and appoints the Agent at the address of the Agent stated above
as the Filing Person's agent upon whom may be served a notice, pleading, subpoena, summons
or other process in any action, investigation or administrative, criminal, quasi-criminal, or
other proceeding (a "Proceeding") arising out of, relating to or concerning the distribution
of the Securities made or purported to be made under the Prospectus, and the Filing Person
hereby irrevocably waives any right to raise as a defence in a Proceeding an alleged lack of
jurisdiction to bring the Proceeding.
12. The Filing Person irrevocably and unconditionally submits to the non-exclusive jurisdiction
of (i) the courts and administrative tribunals of Ontario and (ii) an administrative proceeding
in Ontario, in any Proceeding arising out of, related to or concerning or in any other manner
connected with the distribution of the Securities made or purported to be made pursuant to
the Prospectus.
13. Until six years after completion of the distribution of the Securities made under the
prospectus, the Filing Person shall file a new Submission to Jurisdiction and Appointment of
Agent for Service of Process in this form at least 30 days before termination, for any reason,
of this Submission to Jurisdiction and Appointment of Agent for Service of Process.
14. Until six years after completion of the distribution of the Securities under the prospectus, the
Filing Person shall file an amended Submission to Jurisdiction and Appointment of Agent for
Service of Process at least 30 days before a change in the name or address of the Agent.
15. This Submission to Jurisdiction and Appointment of Agent for Service of Process shall be
governed by and construed in accordance with the laws of [insert province of above address
of Agent].
Dated:
Signature of Filing Person
Print name of person signing and, if the Filing Person is not an
individual, the title of the person
AGENT
The undersigned accepts the appointment as agent for service of process of [Insert name of
Filing Person] under the terms and conditions of the preceding Submission to Jurisdiction and
Appointment of Agent for Service of Process.
Dated:
Signature of Agent
Print name of person signing and, if the Agent is not an individual,
the title of the person
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