Name: Form Test | ASC
Address: 250 5 St SW #600, Calgary, Alberta, T2P 0R4
Telephone: (403) 297-6454

Date

To: Executive Director, Alberta Securities Commission (ASC)

I am filing this report in compliance with the dealer registration exemption in ASC Blanket Order 31-536 Alberta Small Business Finder’s Exemption.

I am filing this report for the first time: Yes No I am filing this report to update a previously filed report Yes No

If you select Yes to the question below, the individual information section will be displayed. If you select No, you will be submitting the form as a Company and the company information section will be displayed.

I am filing this report as an individual Yes No

Individual Information

My full legal name is:

First Name Middle Name Last Name

I am also known as:

First Name Middle Name Last Name

My residential address is (do not include a P.O. box or agent for service):

Address Line 1 Address Line 2 City Province Postal Code

My residential address is the same as my mailing address Yes No

If No, complete the following:

Address Line 1 Address Line 2 City Province Postal Code

My telephone number is My email address is

Collection and use of personal information

The personal information submitted in this report is collected on behalf of and used by the Alberta Securities Commission under the authority granted in securities legislation for the purposes of its administration and enforcement of the securities legislation.

If you have any questions about the collection and use of your personal information, you can contact the Alberta Securities Commission, at the address listed below.

Alberta Securities Commission
Suite 600, 250-5th St. SW
Calgary, AB T2P 0R4
Attention: FOIP Coordinator
Telephone: (403) 297-6454
Toll free in Canada: 1-877-355-0585

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Individual Information

Collection and use of personal information