Unofficial Consolidation: Form 54-101F4 Omnibus Proxy (Proximate Intermediaries)

Unofficial Consolidation: Form 54-101F4 Omnibus Proxy (Proximate Intermediaries)

Unofficial Consolidation Forms

Ontario Securities Commission

Form 54-101F4

Unofficial consolidation current to 2002-07-01

This document is not an official statement of law or policy and should be used for reference purposes only.

FORM 54-101F4

Note:     Terms used in this Form have the meanings given to them in National Instrument 54-101.

The use of this Form is referenced in sections 1.1, 4.1 and 8.2 of National Instrument 54-101.

[Letterhead of Proximate Intermediary]


Subject to the paragraph that follows, [the undersigned], being a registered holder or proxy holder in respect of securities of the reporting issuer specified below, as at the beneficial ownership determination date, hereby appoints [insert names from reporting issuer's management proxy], with power of substitution, to attend, vote and otherwise act for and on behalf of [the undersigned] to the extent of the number of securities specified, in respect of all matters that may come before the meeting of securityholders described below, and at any adjournment or continuance.

The appointees shall not vote, or give a proxy requiring or authorizing another person or company to vote, the securities represented by this omnibus proxy except in accordance with voting instructions received from the beneficial owners whose securities are represented by this omnibus proxy or in accordance with other legal authority to vote the securities.

This instrument supersedes and revokes any prior appointment of proxy made by [the undersigned] with respect to the voting of the securities specified below at such meeting, or at any adjournment thereof.

Reporting issuer:                                             ________________________________

Class/Series of Security:                                ________________________________

ISIN Number:                                                  ________________________________

Number of Securities:                                     ________________________________

Name of Registered Holder of Securities2:    ________________________________

Date of Meeting:                                             ________________________________

Beneficial Ownership Determination Date:    ________________________________

[Include date and signature]


2 [Instruction: Specify if securities are held through more than one registered holder, and specify the number of securities held through each registered holder.]