A. Permitted Client

You are a permitted client because:

• You are an individual who beneficially owns financial assets, as defined in section 1.1 of National Instrument 45-106 Prospectus Exemptions, having an aggregate realizable value that, before taxes but net of any related liabilities, exceeds $5 million.
• Other – you are a person or company that otherwise falls within the definition of a permitted client in section 1.1 of Part 1 in National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations. Please specify the relevant category: ____.

B. Accredited Investor

You are an accredited investor because (check all that apply):

• Your net income before taxes was more than $200,000 in each of the 2 most recent calendar years and you expect it to be more than $200,000 in this 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 2 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.)
• Other - you are a person or company that otherwise falls within the definition of an accredited investor as defined in section 1.1 of National Instrument 45-106 Prospectus Exemptions and in subsection 73.3(1) of the Securities Act, R.S.O. 1990 c. S.5. Please specify the relevant category: ____.

Confirmation (if you are an accredited investor but not a permitted client)

• I confirm that, after taking into account my investment of $__________ today in this issuer:

__ I have not invested more than $25,000 in a single crowdfunding investment, and

__ I have not invested more than $50,000 in all of the crowdfunding investments I have made in this calendar year

C. Retail Investor

You are a retail investor if none of the statements in the previous two sections apply to you.

Confirmation (if you are a retail investor)

• I confirm that, after taking into account my investment of $__________ today in this issuer:

__ I have not invested more than $2,500 in a single crowdfunding investment, and

__ I have not invested more than $10,000 in all of the crowdfunding investments I have made in this calendar year.

Purchaser acknowledgement

First and last name:

Date:

Electronic signature: By clicking the ‘I confirm’ button, I acknowledge that I am signing this form electronically and agree that this is the legal equivalent of my handwritten signature. I will not at any time in the future claim that my electronic signature is not legally binding. The date of my electronic signature is the same as my acknowledgement.

Funding portal information

This section must only be completed if an investor has received advice about this investment from a funding portal registered in the category of an investment dealer or an exempt market dealer.

First and last name of registered individual:

Telephone:

Email:

Name of firm:

Registration Category: