Canada: Competition and Antitrust

1.

Name of Investor:

2.

Mailing Address:

3.

Telephone:

Facsimile:

Internet:

4.

Is the investor a WTO investor or a NAFTA investor? (ultimate control):

Yes

No

5.

Name and address of the person or entity that controls the investor:

6.

Country of origin of investment:

7.

Does not apply – go to 8.

8.

Date of implementation of investment:

9.

Name of the Canadian business being acquired:

10.

Business address of the Canadian business:

11.

Brief description of the business activities of the Canadian business (e.g., manufacturing clothing, wholesaling food, etc.):

12.

If the investor is not a WTO investor or a NAFTA investor, is the Canadian business, immediately prior to the implementation of the investment, "controlled by a WTO investor or a NAFTA investor"?

Yes

No

13.

If the investor is a WTO investor or a NAFTA investor, OR if the Canadian business is, immediately prior to the implementation of the investment, "controlled by a WTO investor or a NAFTA investor", indicate whether the Canadian business:

14.

Where the Canadian business is, immediately prior to the implementation of the investment, controlled outside of Canada, indicate the country of control (ultimate control):

15.

Number of persons employed in connection with the Canadian business:

16.

(a) Give the value of all assets of the entity carrying on the Canadian business and of all other entities in Canada control of which is being acquired in this transaction, or if purchasing assets, give the total value of all assets of the Canadian business being acquired

AND

(b) If the acquisition of the Canadian business is the result of the acquisition of control of a corporation incorporated outside Canada, give the total value of the assets of all entities both in Canada and outside Canada, the control of which is being acquired in this transaction.

17.

Does not apply – go to 18.

18

Indicate if the investment falls within any of the following business activities:

(a)

Publication, distribution or sale of books, magazines, periodicals or newspapers in print or machine readable form (other than the sole activity of their printing or typesetting)

Production, distribution, sale or exhibition of film or video recordings

Production, distribution, sale or exhibition of audio or video music recordings

Publication, distribution or sale of music in print or machine readable form

IF YOU HAVE CHECKED OFF ANY OF THE ABOVE ACTIVITIES, PROVIDE THE FOLLOWING INFORMATION WHERE APPLICABLE. YOU MAY USE APPLICABLE ANNUAL REPORTS, OTHER BUSINESS MATERIAL, OR A SEPARATE ATTACHMENT TO ANSWER ITEMS (b) TO (d):

(b)

a description of the business activities of the investor

(c)

a description of any business activity carried on by the person or entity that controls the investor, if any, that is similar to those indicated in (a)

(d)

a description of any products manufactured or sold, or to be manufactured or sold, and of any services rendered, or to be rendered, by the Canadian business

(e)

in the case of an acquisition of control of a Canadian business, provide the following information:

IF YOU ARE UNABLE TO ANSWER ANY OF THE QUESTIONS RELEVANT TO YOUR INVESTMENT, INDICATE THE REASONS.

_____________________

Date

___________________________________________

[Name of Investor]

[Title of Investor]

Please send this form to:

Industry Canada, Director of Investments
235 Queen Street, Rm. 301B, East Tower
P.O. Box 2800, Station "D"
Ottawa, Ontario K1P 6A5
Fax: (613) 996-2515