TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Debentures and Warrants Issuer: Grown Rogue International Inc. (the “Issuer”) SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. 6. For more information about this investment Please contact: Metamaterial Inc. 1 Xxxxxxxx Xxxxx Xxxxxxxxx, Xxxx Xxxxxx X0X 0X0 Attention: Gxxxxx Xxxxxxxxx Phone: 900 000-0000 E-Mail: gxxxxx.xxxxxxxxx@xxxxxxxxxxxx.xxx Website: mxxxxxxxxxxx.xxx For more information about prospectus exemptions, contact your local securities regulator. You can find contact information at wxx.xxxxxxxxxx-xxxxxxxxxxxxxx.xx. 319188.00003/112949640.6 EXHIBIT II TO SCHEDULE A SECURITIES COMMISSION CONTACT INFORMATION Alberta Securities Commission Sxxxx 000, 000 – 0xx Xxxxxx XX Xxxxxxx, Xxxxxxx X0X 0X0 Telephone: (000) 000 0000 Toll free in Canada: 1-000-000-0000 Facsimile: (000) 000-0000 British Columbia Securities Commission P.X. Xxx 00000, Xxxxxxx Xxxxxx 700 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 Inquiries: (000) 000-0000 Toll free in Canada: 1-800-373-6393 Facsimile: (000) 000-0000 Email: ixxxxxxxx@xxxx.xx.xx The Manitoba Securities Commission 500 – 400 Xx. Xxxx Xxxxxx Winnipeg, Manitoba R3C 4K5 Telephone: (000) 000-0000 Toll free in Manitoba 1-000-000-0000 Facsimile: (000) 000-0000 Financial and Consumer Services Commission (New Brunswick) 80 Xxxxxxxxx Xxxxxx, Xxxxx 000 Xxxxx Xxxx, Xxx Brunswick E2L 2J2 Telephone: (000) 000-0000 Toll free in Canada: 1-866-933-2222 Facsimile: (000) 000-0000 Email: ixxx@xxxx.xx Government of Newfoundland and Labrador Financial Services Regulation Division P.X. Xxx 0000 Xxxxxxxxxxxxx Xxxxxxxx 0xx Xxxxx, Xxxx Xxxxx Pxxxxx Xxxxxx Drive St. John’s, Newfoundland and Labrador A1B 4J6 Attention: Director of Securities Telephone: (000) 000-0000 Facsimile: (000) 000-0000 Government of the Northwest Territories Office of the Superintendent of Securities P.X. Xxx 0000 Xxxxxxxxxxx, Xxxxxxxxx Xxxxxxxxxxx X0X 0X0 Attention: Deputy Superintendent, Legal & Enforcement Telephone: (000) 000-0000 Facsimile: (000) 000-0000 Nova Scotia Securities Commission Sxxxx 000, 0000 Xxxx Xxxxxx Xxxx Tower P.X. Xxx 000 Xxxxxxx, Xxxx Xxxxxx X0X 0X0 Telephone: (000) 000-0000 Facsimile: (000) 000-0000 Government of Nunavut Department of Justice Legal Registries Division P.O. Box 1000, Station 500 0xx Xxxxx, Xxxxx Xxxxxxxx Iqaluit, Nunavut X0A 0H0 Telephone: (000) 000-0000 Facsimile: (000) 000-0000 Ontario Securities Commission 20 Xxxxx Xxxxxx Xxxx, 00xx Xxxxx Xxxxxxx, Xxxxxxx X0X 0X0 Telephone: (000) 000-0000 Toll free in Canada: 1-877-785-1555 Facsimile: (000) 000-0000 Email: exxxxxxxxxxxxxxxxxx@xxx.xxx.xx.xx Public official contact regarding indirect collection ...
TO BE COMPLETED BY THE ISSUER. OR SELLING SECURITY HOLDER
TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Units Issuer: Paramount Gold Nevada Corp. SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. 6. For more information about this investment Chemesis International Inc. Suxxx 0000, 000 Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx, X0X 0X0 Xttention: Amxx Xxxxxx Xmail: amxxxxxxxx@xxxxxxxx.xxx For more information about prospectus exemptions, contact your local securities regulator. You can find contact information at wwx.xxxxxxxxxx-xxxxxxxxxxxxxx.xx. Signature of executive officer of the issuer (other than the purchaser): Date: Form instructions: 1 This form does not mandate the use of a specific font size or style but the font must be legible.
TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Shares of common stock of the Issuer (“Shares”) and warrants to purchase Shares Issuer: XxxXxx Pharmaceuticals, Inc. (the “Issuer”) Purchased from: the Issuer SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Units Issuer: Siyata Mobile Inc. (the “issuer”) SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Common Shares Issuer: Metamaterial Inc. Purchased from: Issuer SECTIONS 2 TO 4 TO BE COMPLETED BY THE SUBSCRIBER
TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Units, each comprised of one Common Share and one Warrant Issuer: XORTX Therapeutics Inc. Purchased from the Issuer SECTION 2 TO 4 TO BE COMPLETED BY THE PURCHASER
TO BE COMPLETED BY THE ISSUER. 1. About your investment Type of securities: Common shares Issuer: Oculus VisionTech Inc. Purchased from: Issuer SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
