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Accredited Investor Verification Request Form
(posted March 11, 2011)


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We recommend our clients who are raising capital in the United States to provide potential investors with the following verification request.  It is something we are now strongly recommending clients in Canada follow as well with a similar form modified for Canada.  Although in theory National Instrument 45-106 states that you can rely on statements and information provided by an investor as being factual; independent third party evidence is the best evidence as to whether an investor is or is not an accredited investor. This type of verification request draws everyone's attention to what is required to be an accredited investor and the seriousness of meeting this requirement.

The verification request form below is presented as an example only.  We  encourage you to contact your own legal counsel to discuss this issue before acting or using this form .  Please feel free, however, to instruct your legal counsel to adapt this form to your own use if you find it useful. We remind you that like all legal documents this verification request form  is not magic.  Under the laws in the US and Canada you need to do sufficient due diligence to confirm an investor actually meets the definition of an "accredited investor".
 


 

QUALIFIED INVESTOR CERTIFICATION AND WAIVER OF CLAIMS

 

[Corporate Address]

Dear Sir or Madam:

I have elected not to provide tax returns and a balance sheet from my accountant to evidence my qualifications under Canadian Securities Regulators and the U.S. Securities Exchange Commission guidelines as a qualified accredited investor. However, I hereby acknowledge and warrant that I am an accredited investor as defined in National Instrument 45-106 in Canada and under Regulation D of the rules and regulations promulgated under the Securities Act of 1933. I have the requisite knowledge and experience in financial and business matters such that I am able to evaluate the merits and risks of the purchase of common shares. Furthermore, although you are not required to confirm my warranty and representation of accredited status, I hereby grant permission for you to contact my accountant, attorney, financial planner or other qualified and appropriate professional to confirm that my income and/or net assets satisfy the minimum “accredited investor” requirements.

Contact Information for my accountant, attorney, financial planner or other qualified and appropriate professional:

Name:




 

Address:



 

 



 

Phone:



 

Fax:



 

Email:



 


I waive all claims and causes of actions against you, your affiliates, partners, investors, agents and officers in the event that I am claiming investor status that does not meet the above criteria as required by the Canadian Securities Regulators and the U.S. Securities Exchange Commission  and the province or state of my residence. In addition, I agree to indemnify and hold harmless you, and your affiliates, investors, agents and officers against any claim by me (and any other owners in my investment entity if I choose to act in any other form than individually) for the above stated claims and causes of action.

Investor Signature:




 

Printed Name:



 


Address:

 
 



 

Phone:



 

Fax:



 

Email:



 

 

   


 


Alixe B. Cormick
Venture Law Corporation

618 - 688 West Hastings Street
Vancouver, B.C.
V6B 1P1
Phone: 604-659-9188
Fax: 604-659-9178
E-mail Us

 


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