Foreign Ownership of Land Regulations (SOR/79-416)

ALBERTAEnergy and Natural Resources

Shareholders / Members

If more than 6 shareholders, use attachment (the attachment will be part of this declaration).

Name:	(Surname, First, Int)
Address:
City / Prov.:
P / Code:	–
No. of Shares:	Voting
	Non-Voting
Are these shares or any of them held subject to a trust?
Yes No
Shareholder an ineligible person (as defined in the RegulationFootnote for *)?
Yes No
If a Corporation, Corporation access no.
Name:	(Surname, First, Int)
Address:
City / Prov.:
P / Code:	–
No. of Shares:	Voting
	Non-Voting
Are these shares or any of them held subject to a trust?
Yes No
Shareholder an ineligible person (as defined in the RegulationFootnote for *)?
Yes No
If a Corporation, Corporation access no.
Name:	(Surname, First, Int)
Address:
City / Prov.:
P / Code:	–
No. of Shares:	Voting
	Non-Voting
Are these shares or any of them held subject to a trust?
Yes No
Shareholder an ineligible person (as defined in the RegulationFootnote for *)?
Yes No
If a Corporation, Corporation access no.
Name:	(Surname, First, Int)
Address:
City / Prov.:
P / Code:	–
No. of Shares:	Voting
	Non-Voting
Are these shares or any of them held subject to a trust?
Yes No
Shareholder an ineligible person (as defined in the RegulationFootnote for *)?
Yes No
If a Corporation, Corporation access no.
Name:	(Surname, First, Int)
Address:
City / Prov.:
P / Code:	–
No. of Shares:	Voting
	Non-Voting
Are these shares or any of them held subject to a trust?
Yes No
Shareholder an ineligible person (as defined in the RegulationFootnote for *)?
Yes No
If a Corporation, Corporation access no.
Name:	(Surname, First, Int)
Address:
City / Prov.:
P / Code:	–
No. of Shares:	Voting
	Non-Voting
Are these shares or any of them held subject to a trust?
Yes No
Shareholder an ineligible person (as defined in the RegulationFootnote for *)?
Yes No
If a Corporation, Corporation access no.

• Return to footnote ^*The Foreign Ownership of Land Regulations

If (We) of solemnly declare that I am (President, Secretary, Director, Officer, Solicitor) of the Corporation and that the information set forth above is correct as of the date of this declaration and I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under Oath.

(Severally) Declared before me at the of in the province of this day of 19 .
	(Signature)
(A Commissioner for Oaths) (Print Name)	(Signatory’s position with the Corporation) Date