Proposed Form F4: OSC Rule - 41-501 - General Prospectus Requirements and Forms (Repealed by 41-801 on March 17, 2008)

ONTARIO SECURITIES COMMISSION FORM 41-501F4
NON-ISSUER FORM OF SUBMISSION TOJURISDICTION
AND APPOINTMENT OF AGENT FOR SERVICE OF PROCESS

1. Name of issuer (the "Issuer"):

2. Jurisdiction of incorporation of Issuer:

3. Address of principal place of business of Issuer:

4. Description of securities (the "Securities"):

5. Date of prospectus (the "Prospectus") under which the Securities are offered:

6. Name of person filing this form (the "Filing Person") and Filing Person's relationship toIssuer:

7. Jurisdiction of incorporation of Filing Person, if applicable, or jurisdiction of residence ofFiling Person:

8. Address of principal place of business of Filing Person:

9. Name of agent for service of process (the "Agent"):

10. Address for service of process of Agent in Canada (which address may be anywhere inCanada):

11. The Filing Person designates and appoints the Agent at the address of the Agent stated aboveas the Filing Person's agent upon whom may be served a notice, pleading, subpoena, summonsor other process in any action, investigation or administrative, criminal, quasi-criminal, orother proceeding (a "Proceeding") arising out of, relating to or concerning the distributionof the Securities made or purported to be made under the Prospectus, and the Filing Personhereby irrevocably waives any right to raise as a defence in a Proceeding an alleged lack ofjurisdiction to bring the Proceeding.

12. The Filing Person irrevocably and unconditionally submits to the non-exclusive jurisdictionof (i) the courts and administrative tribunals of Ontario and (ii) an administrative proceedingin Ontario, in any Proceeding arising out of, related to or concerning or in any other mannerconnected with the distribution of the Securities made or purported to be made pursuant tothe Prospectus.

13. Until six years after completion of the distribution of the Securities made under theprospectus, the Filing Person shall file a new Submission to Jurisdiction and Appointment ofAgent for Service of Process in this form at least 30 days before termination, for any reason,of this Submission to Jurisdiction and Appointment of Agent for Service of Process.

14. Until six years after completion of the distribution of the Securities under the prospectus, theFiling Person shall file an amended Submission to Jurisdiction and Appointment of Agent forService of Process at least 30 days before a change in the name or address of the Agent.

15. This Submission to Jurisdiction and Appointment of Agent for Service of Process shall begoverned by and construed in accordance with the laws of [insert province of above addressof Agent].

Dated:

Signature of Filing Person

Print name of person signing and, if the Filing Person is not anindividual, the title of the person

The undersigned accepts the appointment as agent for service of process of [Insert name ofFiling Person] under the terms and conditions of the preceding Submission to Jurisdiction andAppointment of Agent for Service of Process.

Dated:

Signature of Agent

Print name of person signing and, if the Agent is not an individual,the title of the person