TO BE COMPLETED BY THE REGISTRANT. 2. Registrant information [Instruction: this section must only be completed if a subscriber has received advice from a portfolio manager, investment dealer or exempt market dealer concerning his or her investment.] First and last name of registrant (please print): Registered as: [Instruction: indicate whether registered as a dealing representative or advising representative] Telephone: Email: Name of firm: [Instruction: indicate whether registered as an exempt market dealer, investment dealer or portfolio manager.] Date: SCHEDULE B ELIGIBLE INVESTOR QUESTIONNAIRE (Manitoba Residents - Offering Memorandum Required) The undersigned, as a purchaser of Shares (the “Shares”) of AP CAPITAL MORTGAGE INVESTMENT CORPORATION (the “Corporation”), has represented to the Corporation that the undersigned is an “eligible investor” as defined in section 1.1 of National Instrument 45-106 Prospectus Exemptions. The undersigned has indicated below the categories which it, he or she satisfies to qualify as an “eligible investor”. The undersigned understands that the Corporation is relying on this information in determining to sell securities to the undersigned in a manner exempt from the prospectus requirements of applicable securities laws. The undersigned represents and warrants that it, he or she is [check the applicable item]:
TO BE COMPLETED BY THE REGISTRANT. 2. Registrant information [Instruction: this section must only be completed if a subscriber has received advice from a portfolio manager, investment dealer or exempt market dealer concerning his or her investment.] First and last name of registrant (please print): Registered as: [Instruction: indicate whether registered as a dealing representative or advising representative] Telephone: Email: Name of firm: [Instruction: indicate whether registered as an exempt market dealer, investment dealer or portfolio manager.] Date: Complete this form if you are: • A Subscriber in Manitoba, Xxxxxx Xxxxxx Island, Yukon, Northwest Territories or Nunavut • Relying on the Offering Memorandum Exemption; and • Purchasing Units for Greater than $10,000 APPENDIX II ELIGIBLE INVESTOR QUESTIONNAIRE The undersigned, as a purchaser of units (the “Units”) of Capital Direct I Income Trust (the “Trust”), has represented to the Trust and Capital Direct Management Ltd. (the “Manager”) that the undersigned is an “eligible investor” as defined in section 1.1 of National Instrument 45-106 – Prospectus Exemptions. The undersigned has indicated below the categories which it, he or she satisfies to qualify as an “eligible investor”. The undersigned understands that each of the Trust and the Manager is relying on this information in determining to sell securities to the undersigned in a manner exempt from the prospectus requirements of applicable securities laws and the Trust or the Manager may require additional information or action to be taken by the undersigned to verify the undersigned’s eligibility for this exemption. ELIGIBLE INVESTOR STATUS The undersigned represents and warrants that it, he or she is [check each applicable item]: □
TO BE COMPLETED BY THE REGISTRANT. 2. Registrant information [Instruction: this section must only be completed if an investor has received advice from a portfolio manager, investment dealer or exempt market dealer concerning his or her investment.] First and last name of registrant (please print): Registered as: Telephone: Email: Name of firm: Date: EXHIBIT “III” RISK ACKNOWLEDGEMENT FOR PURCHASERS RELYING ON THE OFFERING MEMORANDUM EXEMPTION THIS “EXHIBIT III” IS TO BE COMPLETED BY PURCHASERS SUBSCRIBING UNDER THE OFFERING MEMORANDUM INVESTOR EXEMPTION PROVIDED FOR UNDER THE SUBSCRIPTION AGREEMENT. FORM 45-106F4 W A R N I N G Risk Acknowledgement I acknowledge that this is a risky investment: • I am investing entirely at my own risk. • No securities regulatory authority or regulator has evaluated or endorsed the merits of these securities or the disclosure in the offering memorandum. • I will not be able to sell these securities except in very limited circumstances. I may never be able to sell these securities • I could lose all the money I invest. I am investing $ [total consideration] in total; this includes any amount I am obliged to pay in the future. Cordillera Minerals 2021 Flow-Through Limited Partnership will pay $ [amount of fee or commission] of this to [name of person selling the securities] as a fee or commission. I acknowledge that this is a risky investment and that I could lose all the money I invest. Date Signature of Purchaser Print Name of Purchaser SIGN 2 COPIES OF THIS DOCUMENT. KEEP ONE COPY FOR YOUR RECORDS You have 2 Business Days to cancel your purchase. To do so, send a notice to Cordillera Minerals 2021 Flow-Through Limited Partnership, stating that you want to cancel your purchase. You must send the notice before midnight on the 2nd Business Day after you sign the agreement to purchase the securities. You can send the notice by fax or email or deliver it in person to Cordillera Minerals 2021 Flow-Through Limited Partnership at its business address. Keep a copy of the notice for your records. Cordillera Minerals 2021 Flow-Through Limited Partnership 1100 – 0000 Xxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 Attention: Xxxxx XxXxxx Tel: (000) 000-0000 Email: xxxxxxx@xxxxxxxxxxxxxxxxxx.xx Investment Fund Manager Fieldhouse Capital Management Inc. 0000 Xxxxxxxx Xx #000 Xxxxxxxxx, Xxxxxxx Xxxxxxxx X0X 0X0 Attention: Xxxx Xxxxx Phone: (000) 000-0000 Email: xxxx.xxxxx@xxxxxxxxxxxxx.xxx You are buying Exempt Market Securities. They are called exempt market securitie...
