Notice 2011-001 Housekeeping Amendments – Personal Information Form – CNSX Markets Inc.

Introduction

In accordance with the Rule Review Process set out in Appendix B of the CNSX Markets Inc. ("CNSX Markets") Recognition Order, CNSX Markets has adopted, and the OSC approved, amendments to the CNSX Form 3 -- Personal Information Form (the "Form"). The amendments are considered housekeeping in nature and are therefore not public interest amendments.

Reasons for the Amendments

The changes to the Form reflect current practice, and do not create any new requirements. For the OPP to conduct the criminal record searches, two pieces of ID must be submitted with the Form. The OPP has changed practices over time, and CNSX Markets has complied simply by requesting information in advance or following up with the applicants individually.

There are no new requirements or obligations as a result of the Form amendments, which have been made in accordance the housekeeping provisions of the Rule Review Process. Applicants are not required to submit new forms as a result of the changes.

Text of Amendments

The changes to the form include:

• on page 1 under General Instructions -- a correction to the name of the Form

• on page 1, the addition of point 5: " All forms must be accompanied by a clear photocopy of two pieces of identification issued by a government authority (such as a driver's license or passport). A list of acceptable identification can be found on page 13. "

• on page 1, clarification of the "name" field, and addition of "Name of CNSX Listed Company (or issuer seeking listing)."

• page 2 under (b) Personal Information, the addition of an email address field.

• page 13 -- list of acceptable forms of ID and an explanation of more specific requirements:

"One piece of identification must contain a recognizable photograph of you taken within the last 5 years. The pieces of identification must confirm your full given name, surname, date of birth, gender and current mailing address. Expired documents are not acceptable."

A blacklined copy of the Form reflecting the amendments is attached as Appendix A.

The new Form is available on the CNSX website under "Info for Issuers".

Effective Date

The Amendments are effective immediately.

Questions about CNSX Rules, Policies or Forms may be directed to:

Mark Faulkner,

Director, Listings and Regulation

416.572.2000 x2305

Email: [email protected]

 

Appendix A

FORM 3

PERSONAL INFORMATION FORM

General Instructions

1. This Personal Application Information Form ("Form") is to be completed by

(a) every individual who, if the securities of the Applicant Issuer described below are accepted for listing on CNSX, will at the time of listing be a Related Person of the Applicant Issuer and

(b) each director, senior officer and person who directly or indirectly owns, controls or exercises discretion over 20% or more of the outstanding voting shares of any non-individual that will, if the securities of the Applicant Issuer described below are accepted for listing on CNSX, be a Related Person of the Applicant Issuer..

2. This Form is also to be completed where the securities of the Applicant Company are listed on CNSX by

(a) each individual who has become or proposes to become a Related Person of the CNSX Issuer and

(b) each director, senior officer and each person who directly or indirectly owns, controls or exercises discretion over 20% or more of the outstanding voting shares of any non-individual who has become or proposes to become a Related Person of the CNSX Issuer.

3. All items must be completed on the Form. Each Form must be signed (and initialled where necessary) manually and not mechanically or electronically. No facsimiles or copied versions will be accepted. Please type or print using BLOCK letters. Failure to respond to all questions accurately and completely may delay the processing of the application of the Applicant Issuer and may result in the denial of the application.

4. All attachments pertaining to any question must be made exhibits to the Form and each one must be so marked. All signatures must be originals. The Commissioner of Oaths before whom the statutory declaration at the end of the form is made, as well as the person completing the Form, must initial all attachments.

5. All forms must be accompanied by a clear photocopy of two pieces of identification issued by a government authority (such as a driver's license or passport). A list of acceptable identification can be found on page 13.

- - - - - - - - - - - - - - - - - - - -

Name of Applicant's Name:

Name of CNSX Listed Company (or issuer seeking listing):

Original Listing:

Listed Company:

- - - - - - - - - - - - - - - - - - - -

1. Basic Information

(a) Identification

Surname:	Legal First Name:
Full Middle Name(s):	Check here if no middle name(s): [ ]
Name(s) by which you are comonly known:

(b) Personal Information -- No Abbreviations

Gender:		Date of Birth:
[ ] Male	[ ] Female	Day:	Month:	Year:
Place of birth (City Province/State, Country)
Email address:

(c) Current Residential Address -- No Abbreviations

Street Address:	City:	Province/State:
Country:	Postal/ZIP:	Res. Telephone Number:
		(___)

(d) Residential History for Past 15 years -- No Abbreviations

(Provide attachments if additional space is necessary)

Street address, City, Province/State, Country, Postal/ZIP	From				To
	M		Y		M		Y
_________________________	___	___	___	___	___	___	___	___
_________________________	___	___	___	___	___	___	___	___
_________________________	___	___	___	___	___	___	___	___
_________________________	___	___	___	___	___	___	___	___

(e) Citizenship -- No Abbreviations

Citizenship:

If not a Canadian citizen, please indicate number of years continuous residence in Canada:

If you are a U.S. citizen or hold a U.S. Social Security Number, please provide it here:

If you are a Hong Kong citizen or hold a Hong Kong Indentification Number:

If you have a Canadian Social Insurance Number, please provide it here:

(f) Professional Designation(s)

Please list all professional designations which you have and professional associations to which you belong (please include membership numbers where applicable):

_________________________

_________________________

(g) -- Present or Proposed Position with the Applicant Issuer

Check below as applicable		Provide the Date Elected/ Appointed/ Position Achieved						Title
		M		D		Y
[ ]	Director	___	___	___	___	___	___	____________________
[ ]	Officer	___	___	___	___	___	___	____________________
[ ]	Other (provide details)
	(see General Instructions -- Pg.1)	___	___	___	___	___	___	____________________

(h) Positions with Other Issuers

Provide the names of any public reporting issuers and any issuer with continuous disclosure obligations in any jurisdiction of which you are now, or during the last 10 years, have been a director, promoter, insider or control person, the positions you held and the periods during which you held those positions. Use an attachment if necessary.

Name of		Positions	From				To
Reporting Issuers	Market	Held with Issuer
			M		Y		M		Y
_______________	__________	__________	___	___	___	___	___	___	___	___
_______________	__________	__________	___	___	___	___	___	___	___	___
_______________	__________	__________	___	___	___	___	___	___	___	___

2. Change of Name or Use of Different Name

Instructions

Have you ever had, used, operated under, or carried on business under any name other than the names mentioned in Question 1a of this form, or have you ever been known under any other name? (Name changes resulting from marriage, divorce, court order or any other process should be included here, giving appropriate dates.)

Yes:	[ ]
No:	[ ]

Previous Names	From		To
	Month	Year	Month	Year
_________________________	_____	_____	_____	_____
_________________________	_____	_____	_____	_____

Instructions Regarding Questions 3 to 7

Full details are required as attachments in respect of any question to which the answer is yes. These details must include the circumstances, the relevant dates, the names of the parties involved, and the final determination if known. All questions must be answered with YES or NO, unless otherwise specified.

3. Proceedings by Regulators

(a) Have you personally ever been the subject of a cease trading order issued by any authority regulating trading in securities?

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

_________________________

(b) Have you, or has any partnership or company of which you were at the time of such event a partner, officer, director, or beneficial owner of more than 10% of the voting securities, ever been denied the benefit of any exemption provided by any act regulating trading in securities?

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

_________________________

(c) Have you, or has any partnership or company of which you were at the time of such event a partner, officer, director, or beneficial owner of more than 10% of the voting securities, ever been the subject of disciplinary action, not disclosed in 3(b) above, undertaken by any authority regulating or supervising trading in securities, including any stock exchange, association of investment dealers or similar organization? (Do not include cease-trading orders.)

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

_________________________

(d) Have you personally ever been the subject of disciplinary action, not disclosed in 3(a), (b) or (c) above, undertaken by any tribunal, organization or society responsible for the regulation of a profession?

Yes: [ ]

No: [ ]

Details:

_________________________

4. Offences Under The Law

Note: If a pardon under the Criminal Records Act (Canada) has been formally requested and you have received formal written notice that such pardon has been granted and it has not been revoked, you are not obliged to disclose any such pardoned offence. In such circumstances, the appropriate response would be: "Yes, pardon granted on (date)."

(a) Past Convictions Involving Securities or Commodities

Have you ever been convicted under any law of any province, territory, state or country of any offence relating to trading in securities, commodities or commodity futures contracts, or with the theft of securities, or with any related offence, or been a party to any proceedings taken on account of fraud arising out of any trade in or advice respecting securities?

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

(b) Past Convictions Involving Other Contraventions or Criminal Offences

Have you ever been convicted under any law of any province, territory, state or country for contraventions or criminal offences not noted in 4(a) above? (Do not include non-criminal traffic convictions.)

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

(c) Current Charges or Indictments

Are you currently the subject of a charge or indictment, under any law of any province, territory, state or country for contraventions, criminal offences, or other conduct of the type described in 4(a) or 4(b) above?

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

_________________________

(d) Partnership or Company Convictions or Current Charges or Indictments

Has any partnership or company of which you were at the time of such event a partner, officer, director, or beneficial owner of more than 10% of the voting securities, ever been convicted, or is any partnership or company in which you hold such a position currently the subject of a charge or indictment, under any law of any province, territory, state or county for contraventions, criminal offences, or other conduct of the type described in 4(a) or 4(b) above?

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

5. Civil Proceedings

(a) Has a court in a civil proceeding ever held that you or any partnership or company of which you were at the time of such event a partner, officer, director, or beneficial owner of more than 10% of the voting securities committed fraud or similar conduct?

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

_________________________

(b) Are there any civil proceedings now pending in which fraud or similar conduct on the part of you or any partnership or company of which you are or were at the time such proceedings commenced a partner, officer, director, or beneficial owner of more than 10% of the voting securities is alleged?

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

_________________________

6. Bankruptcy

(a) Have you ever been declared bankrupt, made a voluntary assignment in bankruptcy, made a compromise or agreement with your creditors or gone out of business leaving debts outstanding, or produced a declaration under the Quebec Voluntary Deposit of Salary Wages Law, or has a receiver or a receiver and manager appointed by or at the request of your creditors ever assumed control of your assets?

Yes: [ ]

No: [ ]

Jurisdiction of Filing: _________________________

Details:

_________________________

_________________________

_________________________

If so, have you been discharged? (A copy of the discharge must be attached.)

_________________________

_________________________

_________________________

(b) Has any partnership or company of which you were at the time of such event a partner, director, officer, or beneficial owner of more than 10% of the voting securities ever been declared bankrupt or made a voluntary assignment in bankruptcy, or had control of its assets assumed by a receiver and manager appointed by or at the request of its creditors?

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

_________________________

7. Judgment Or Garnishment

Is any judgment or garnishment outstanding against you, in any civil court in any province, state or country for damages or other relief in respect of a fraud or for any reason whatsoever?

Yes: [ ]

No: [ ]

Details:

_________________________

_________________________

_________________________

Caution

A person who makes a false statement by statutory declaration commits an indictable offence under the Criminal Code that is punished by imprisonment for a term not exceeding fourteen (14) years. Steps will be taken to verify the answers you have given in this Form, including verification of information relating to any previous criminal record.

Acknowledgement and Consent to Collection and Use of Personal Information

I HAVE READ AND UNDERSTOOD THE PERSONAL INFORMATION COLLECTION POLICY ("PRIVACY POLICY") OF CANADIAN NATIONAL STOCK EXCHANGE. I HEREBY AUTHORIZE AND CONSENT TO THE COLLECTION AND USE BY ANY OF CANADIAN NATIONAL STOCK EXCHANGE AND ITS SUBSIDIARIES, AFFILIATES, REGULATORS AND AGENTS OF ANY INFORMATION WHATSOEVER (WHICH MAY INCLUDE PERSONAL, CREDIT, OR OTHER INFORMATION) FROM ANY SOURCE, INCLUDING WITHOUT LIMITATION AN INVESTIGATIVE AGENCY OR A RETAIL CREDIT AGENCY AS PERMITTED BY LAW IN ANY JURISDICTION IN CANADA OR ELSEWHERE. I ACKNOWLEDGE AND AGREE THAT SUCH INFORMATION MAY BE SHARED WITH AND RETAINED BY CANADIAN NATIONAL STOCK EXCHANGE AND ITS SUBSIDIARIES, AFFILIATES, REGULATORS AND AGENTS INDEFINITELY.

_________________________

Date

 

_________________________

Signature

ALL ATTACHMENTS MUST BE INITIALED BY THE PERSON COMPLETING THE FORM AND BY THE COMMISSIONER FOR OATHS. ALL SIGNATURES MUST BE ORIGINALS.

LIST ANY ATTACHMENTS:

8. -- Statutory Declaration

I, _________________________ (Name of Person Completing this Form)

Do Solemnly Declare That

(a) I have read and understand the questions, caution and acknowledgement in this Form;

(b) The answers I have given to the questions in this Form and in any attachments to the Form are true and correct except where stated to be to the best of my knowledge in which case I believe the answers to be true; and

(c) I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath and by virtue of the Canada Evidence Act.

SWORN/DECLARED before me at the

City of __________ in the Province
(or State) of __________ this __________ day	_________________________
of __________, 20_____.

_________________________

A Commissioner of Oaths/Notary Public

My Appointment Expires: __________

NOTARY'S SEAL:

Note: Where this form is sworn outside the Province of Ontario, it must be executed in the presence of a duly authorized Notary Public in and for the jurisdiction in which it is sworn.

 

Release and Discharge Relating to Consent to Disclosure of Criminal Record Information

_________________________
Surname	Given Name	Middle Name	Date of Birth (dd/mmm/yyyy)	[ ]	Male
				[ ]	Female
_________________________
Previous Surnames (eg. Former marriage, maiden)
_________________________
Address (number, street, apt., lot, concession, township, rural route #, city, postal code)
_________________________
Occupation
_________________________
I hereby authorize the Ontario Provincial Police (the OPP) to release records of criminal convictions for which a pardon has not been granted, records of discharges which have not been removed from the CPIC system in accordance with the Criminal Records Act, and records of outstanding criminal charges of which the OPP is aware, to the person(s) listed below.
_________________________

Name	Title
Jason Daigle	Investigative Research and Disclosure
_________________________
Department and Branch
Investigative Research & Regulation
_________________________
Name of Organization
Canadian National Stock Exchange (CNSX)
_________________________

Release and Discharge

I hereby release and forever discharge Her Majesty the Queen in right of Ontario, the Commissioner of the Ontario Provincial Police and all members and employees of the OPP from any and all actions, claims and demands for damages, loss or injury howsoever arising which may hereafter be sustained by myself as a result of the disclosure of information by the OPP to the above named organization.

I acknowledge that information so disclosed may be confirmed only by a comparison of the fingerprints on file to which the information relates and my fingerprints.

	____________________	____________________
	Signature	Date

Confidential

This record and the information contained therein, is being provided in confidence and shall not be disclosed to any person with the exception of the person(s) named above without the express written consent of the Commissioner of the OPP.

Based on a name check only, and having a birth date as provided above -- a records check:

[ ] fails to reveal any record relating to the above subject.

[ ] indicates the following information may relate to the above subject.

Details cannot be certified as relating to the subject of inquiry, without a fingerprint comparison.

PERSONAL INFORMATION COLLECTION POLICY

Canadian National Stock Exchange and its subsidiaries, affiliates, regulators and agents (collectively, "CNSX") collect and use the information (which may include personal, credit, confidential, criminal or other information) which you have provided in this personal information form ("PIF") for the following purposes:

• To conduct a background check of the individual or company completing the PIF;

• To verify the information provided in the PIF;

• To determine whether an individual is suitable to be associated with a listed CNSX Issuer;

• To determine whether an issuer is suitable for listing;

• To determine whether allowing an issuer to be listed or allowing an individual to be associated with a listed CNSX Issuer could give rise to investor protection concerns or could bring the CNSX marketplace into disrepute;

• To conduct enforcement proceedings;

• To ensure compliance with CNSX Requirements and applicable securities legislation; and

• To fulfil CNSX's obligation to regulate its marketplace.

CNSX also collects information, including personal information, from other sources, including but not limited to securities regulatory authorities, law enforcement and self-regulatory authorities, regulation service providers and their subsidiaries, affiliates, regulators and agents. CNSX may disclose personal information to these entities or otherwise as provided by law and they may use it for their own investigations.

CNSX may use third parties to process information or provide other adminstrative services. Any third party will be obliged to adhere to the security and confidentiality provisions set out in this policy.

All personal information provided to or collected by or on behalf of CNSX and that is retained by CNSX is kept in a secure environment. Only those employees who need to know the information for the purposes listed above are permitted access to the information or any summary thereof. Employees are instructed to keep the information confidential at all times.

Information about you that is retained by CNSX and that you have identified as inaccurate or obsolete will be corrected or removed.

If you wish to consult your file or have any quesitons about this policy or our practices, please write the Chief Privacy Officer, Canadian National Stock Exchange, 220 Bay Street -- 9^th Floor, Toronto, ON, M5J 2W4.

 

Acceptable Forms of Photo Identification

All forms must be accompanied by a clear photocopy of two pieces of identification issued by a government authority (such as a driver's license or passport). However,

• One piece of identification must contain a recognizable photograph of you taken within the last 5 years.

• The pieces of identification must confirm your full given name, surname, date of birth, gender and current mailing address.

• Expired documents are not acceptable.

• Driver's Licence

• BYID (issued by the LCBO)

• Military Employment Card

• Canadian Citizenship Card

• Indian Status Card

• International Student Card

• Passport

• Permanent Resident Card

• PAL-Possession & Acquisition Licence

• CNIB Card

Acceptable Forms of Non-Photo Identification

• Birth Certificate

• Baptismal Certificate

• Hunting Licence

• Outdoors Card

• Canadian Blood Donor Card

• Immigration Papers

Common ID Submitted that is not acceptable

Health Cards -- cannot be accepted for identification purposes under the Personal Health Information Protection Act, 2004 (Section 34).

Social Insurance Cards (SIN) -- It is a punishable offence to photocopy a SIN card pursuant to the Employment Insurance Act, Part VI, (Section 141(c)).