TO BE COMPLETED BY THE ISSUER. 6. For more information about this investment
TO BE COMPLETED BY THE ISSUER. 1. About your investment SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
2. Risk acknowledgement
3. Family, friend or business associate status
A) You are:
1) [check all applicable boxes]
2) [check all applicable boxes]
B) You are a family member of ____________________________________ [Instruction: Insert the name of the person who is your relative either directly or through his or her spouse], who holds the following position at the issuer or an affiliate of the issuer: _______________________________. You are the ____________________________ of that person or that person’s spouse. [Instruction: To qualify for this investment, you must be (a) the spouse of the person listed above or (b) the parent, grandparent, brother, sister, child or grandchild of that person or that person’s spouse.] Form 1C- 2 - Form 45-106F12
C) You are a close personal friend of _______________________________ [Instruction: Insert the name of your close personal friend], who holds the following position at the issuer or an affiliate of the issuer: _______________________________. You have known that person for _____ years.
D) You are a close business associate of ______________________________ [Instruction: Insert the name of your close business associate], who holds the following position at the issuer or an affiliate of the issuer: ____________________________. You have known that person for _____ years.
4. Your name and signature
TO BE COMPLETED BY THE ISSUER. 1. About your investment SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
2. Risk acknowledgement
3. Family, friend or business associate status
A) You are:
1) [check all applicable boxes] ☐ a director of the issuer or an affiliate of the issuer ☐ an executive officer of the issuer or an affiliate of the issuer ☐ a control person of the issuer or an affiliate of the issuer ☐ a founder of the issuer OR 2) [check all applicable boxes] ☐ a person of which a majority of the voting securities are beneficially owned by, or a majority of the directors are, (i) individuals listed in (1) above and/or (ii) family members, close personal friends or close business associates of individuals listed in (1) above ☐ a trust or estate of which all of the beneficiaries or a majority of the trustees or executors are (i) individuals listed in (1) above and/or (ii) family members, close personal friends or close business associates of individuals listed in (1) above
B) You are a family member of ____________________________________ [Instruction: Insert the name of the person who is your relative either directly or through his or her spouse], who holds the following position at the issuer or an affiliate of the issuer: _______________________________. You are the ____________________________ of that person or that person’s spouse. [Instruction: To qualify for this investment, you must be (a) the spouse of the person listed above or (b) the parent, grandparent, brother, sister, child or grandchild of that person or that person’s spouse.]
C) You are a close personal friend of _______________________________ [Instruction: Insert the name of your close personal friend], who holds the following position at the issuer or an affiliate of the issuer: _______________________________. You have known that person for _____ years.
D) You are a close business associate of ______________________________ [Instruction: Insert the name of your close business associate], who holds the following position at the issuer or an affiliate of the issuer: ____________________________. You have known that person for _____ years.
4. Your name and signature
TO BE COMPLETED BY THE ISSUER. 1. About your investment SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
2. Risk acknowledgement Liquidity risk – You may not be able to sell your investment quickly – or at all. Lack of Information – You may receive little or no information about your investment. The information you receive may be limited to the information provided to you by the family member, friend or close business associate specified in Section 3 of this form.
TO BE COMPLETED BY THE ISSUER. 1. About your investment SECTIONS 2 TO 4 TO BE COMPLETED BY THE PURCHASER
2. Risk acknowledgement
TO BE COMPLETED BY THE ISSUER. 1. About your investment SECTIONS 2 TO 4 TO BE COMPLETED BY THE SUBSCRIBER
2. Risk acknowledgement
3. Accredited investor status
4. Your name and signature
TO BE COMPLETED BY THE ISSUER. OR SELLING SECURITY HOLDER
1. About your investment Sections 2 to 4 – TO BE COMPLETED BY THE PURCHASER
2. Risk acknowledgement
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 The
2. Risk acknowledgement This investment is risky. Initial that you understand that: Your initials Risk of loss – You could lose your entire investment of U.S.$ [Instruction: Insert the total dollar amount of the investment.] Liquidity risk – You may not be able to sell your investment quickly – or at all. Lack of information – You may receive little or no information about your investment. Lack of advice – You will not receive advice from the salesperson about whether this investment is suitable for you unless the salesperson is registered. The salesperson is the person who meets with, or provides information to, you about making this investment. To check whether the salesperson is registered, go to xxx.xxxxxxxxxxxxxxxxx.xx.
3. Accredited investor status You must meet at least one of the following criteria to be able to make this investment. Initial the statement that applies to you. (You may initial more than one statement.) The person identified in section 6 is responsible for ensuring that you meet the definition of “accredited investor” as such term is defined in National Instrument 45-106 – Prospectus Exemptions. That person, or the salesperson identified in section 5, can help you if you have questions about whether you meet these criteria. Your initials · Your net income before taxes was more than $200,000 in each of the two most recent calendar years, and you expect it to be more than $200,000 in the current calendar year. (you can find your net income before taxes on your personal income tax return.) · Your net income before taxes combined with your spouse’s was more than $300,000 in each of the two most recent calendar years, and you expect your combined net income before taxes to be more than $300,000 in the current calendar year. · Either alone or with your spouse, you own more than $1 million in cash and securities, after subtracting any debt related to the cash and securities. · Either alone or with your spouse, you have net assets worth more than $5 million. (Your net assets are your total assets (including real estate) minus your total debt.)
4. Your name and signature By signing this form, you confirm that you have read this form and you understand the risks of making this investment as identified in this form. First and last name (ple...
TO BE COMPLETED BY THE ISSUER. For more information about this investment Tri City Group Monthly Income Mortgage Trust c/o Tri City Fund Management Ltd. 1000 – 000 Xxxx Xxxxxxxx Xxxxxx Xxxxxxxxx, XX X0X 0X0 Telephone: 000.000.0000 Email: xxxxxxxxxxxxx@xxxxxxxxxxxx.xx For more information about prospectus exemptions, contact your local securities regulator. You can find contact information at xxx.xxxxxxxxxx-xxxxxxxxxxxxxx.xx. The purpose of this Questionnaire is to assure Tri City Group Monthly Income Mortgage Trust (the “Issuer”) that the undersigned (the “Purchaser”) will meet certain requirements for the registration and prospectus exemptions provided for under National Instrument 45-106 (“NI 45-106”), as adopted by the various provincial and territorial Securities Commissions in Canada, in respect of a proposed private placement of securities by the Issuer (the “Transaction”). The Issuer will rely on the information contained in this Questionnaire for the purposes of such determination. The undersigned Purchaser covenants, represents and warrants to the Issuer that the Purchaser satisfies one or more of the categories of “eligible investor” (as that term is defined in NI 45-106) indicated below (please check the appropriate box):
TO BE COMPLETED BY THE ISSUER. 6. For more information about this investment
(i) With assets under management in excess of $5,000,000,
(ii) That is not formed for the specific purpose of acquiring the securities offered, and
(iii) Whose prospective investment is directed by a person who has such knowledge and experience in financial and business matters that such family office is capable of evaluating the merits and risks of the prospective investment;
☐ A “family client,” as defined in rule 202(a)(11)(G)-1 under the Investment Advisers Act of 1940 (17 CFR 275.202(a)(11)(G)-1)), of a family office meeting the requirements in category 23 above and whose prospective investment in the issuer is directed by such family office as referenced above; ☐ A natural person who is a “knowledgeable employee,” as defined in rule 3c-5(a)(4) under the Investment Company Act of 1940 (17 CFR 270.3c-5(a)(4)), of the issuer of the securities being offered or sold where the issuer would be an investment company, as defined in Section 3 of such Act, but for the exclusion provided by either Section 3(c)(1) or Section 3(c)(7) of such Act; or ☐ The Investor is not an Accredited Investor and does not meet any of the above criteria. INVESTOR: (Print Full Name of Entity or Individual) By: (Signature) Name: Title: (If signing on behalf of entity) The undersigned (the “Subscriber”) represents covenants and certifies to the Corporation that:
i. the Subscriber (and if the Subscriber is acting as agent for a disclosed principal, such disclosed principal) is not resident in Canada or the United States or subject to applicable securities laws of Canada or the United States;
ii. the issuance of the securities in the capital of the Corporation under this agreement (the “Securities” ) by the Corporation to the Subscriber (or its disclosed principal, if any) may be effected by the Corporation without the necessity of the filing of any document with or obtaining any approval from or effecting any registration with any governmental entity or similar regulatory authority having jurisdiction over the Subscriber (or its disclosed principal, if any);
iii. the Subscriber is knowledgeable of, or has been independently advised as to, the applicable securities laws of the jurisdiction which would apply to this subscription, if there are any;
iv. the issuance of the Securities to the Subscriber (and if the Subscriber is acting as agent for a disclosed principal, such disclosed principal) complies with the requirements of all applicable ...
