Name of Transferor. REASON FOR TRANSFER – For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below). Gift Estate Private Sale Other (or no change in ownership) Date of Event (Date of gift, death or sale): Value per Warrant on the date of event: CERTAIN REQUIREMENTS RELATING TO TRANSFERS – READ CAREFULLY
Name of Transferor. REASON FOR TRANSFER – For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below). CERTAIN REQUIREMENTS RELATING TO TRANSFERS – READ CAREFULLY
Name of Transferor. Name of Transferee (if the Transferred Shares are to be transferred to two or more individuals as co-owners, please specify if the Transferred Shares are to be held by such Transferees as joint tenants, tenants by the entirety or tenants in common):
Name of Transferor. REASON FOR TRANSFER – For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below). Gift Estate Private Sale Other (or no change in ownership) Date of Event (Date of gift, death or sale): Value per Warrant on the date of event: CERTAIN REQUIREMENTS RELATING TO TRANSFERS – READ CAREFULLY Canada and the USA: A Medallion Signature Guarantee obtained from a member of an acceptable Medallion Signature Guarantee Program (STAMP, SEMP, NYSE, MSP). Many commercial banks, savings banks, credit unions, and all broker dealers participate in a Medallion Signature Guarantee Program. The Guarantor must affix a stamp bearing the actual words “Medallion Guaranteed”, with the correct prefix covering the face value of the certificate. Canada: A Signature Guarantee obtained from an authorized officer of the Royal Bank of Canada, Scotia Bank or TD Canada Trust. The Guarantor must affix a stamp bearing the actual words “Signature Guaranteed”, sign and print their full name and alpha numeric signing number. Signature Guarantees are not accepted from Treasury Branches, Credit Unions or Caisse Populaires unless they are members of a Medallion Signature Guarantee Program. For corporate holders, corporate signing resolutions, including certificate of incumbency, are also required to accompany the transfer, unless there is a “Signature & Authority to Sign Guarantee” Stamp affixed to the transfer (as opposed to a “Signature Guaranteed” Stamp) obtained from an authorized officer of the Royal Bank of Canada, Scotia Bank or TD Canada Trust or a Medallion Signature Guarantee with the correct prefix covering the face value of the certificate.
