The S.M.A.R.T. Management People!™

1. IDENTIFICATION

LAST NAME
FIRST, SECOND AND THIRD NAMES

ADDRESS

CITY
PROV/STATE
COUNTRY
POSTAL / ZIP CODE

Provide any legal names, other than the name given in 1, and assumed names by which you have carried on business or otherwise been known, such as a registered sole proprietorship. Please include any name change(s) resulting from marriage, divorce, court order or other process.	FROM		TO
	Y	M	Y	M

2. EDUCATIONAL HISTORY- Provide your educational history starting with the most recent.

INSTITUTION	LOCATION	DEGREE OR DIPLOMA	DATE OBTAINED
INSTITUTION	LOCATION	DEGREE OR DIPLOMA	Y	M	D

PROFESSIONAL DESIGNATION - provide any professional designation held, for example Barrister & Solicitor, C.A, C.G.A., P.Eng, P. Geo and C.F.A. and indicate by whom and the date the designations were granted.

PROFESSIONAL DESIGNATION	GRANTER OF DESIGNATION	DATE GRANTED			IN EFFECT - YES or NO
PROFESSIONAL DESIGNATION	GRANTER OF DESIGNATION	Y	M	D	IN EFFECT - YES or NO
					Yes No
					Yes No

3. PERSONAL INFORMATION

RESIDENTIAL TELEPHONE NUMBER	BUSINESS TELEPHONE NUMBER	FAX NUMBER	EMAIL (INTERNET)

MARITAL STATUS	FULL NAME OF SPOUSE - include common law	OCCUPATION OF SPOUSE

DATE OF BIRTH			PLACE OF BIRTH
Y	M	D	CITY	PROVINCE / STATE / PARISH	COUNTRY

CITIZENSHIP
If you are not a Canadian citizen: [1] Are you a permanent resident of Canada? YES NO [2] What is your Nationality? If yes, number of years of continues residence in Canada: years
PASSPORT COUNTRY OF ISSUE	NAME OF CITY WHERE PASSPORT WAS ISSUED	DATE PASSPORT ISSUED			PASSPORT NUMBER
		Y	M	D

DRIVER'S LICENSE NUMBER	PROVINCE / STATE WHERE DRIVER'S LICENSE WAS ISSUED	SOCIAL INSURANCE / SECURITY NUMBER

4. RESIDENTIAL HISTORY- Provide all residential addresses for the past 10 YEARS starting with your current principal residential address.

STREET ADDRESS, CITY, PROVINCE/STATE, COUNTRY & POSTAL / ZIP CODE	FROM		TO
	Y	M	Y	M

5. POSITIONS IN OTHER ISSUERS - If you are or were an employee or engaged by an Issuing entity, please provide the names of reporting issuers and of issuers with continues disclosure obligations in other jurisdictions of which you are now, or during the last five years, have been a director, officer, promoter or control person, the positions you held and the periods during which you held those positions.

NAMES OF (REPORTING) ISSUERS	POSITION HELD WITH ISSUER	FROM		TO
NAMES OF (REPORTING) ISSUERS	POSITION HELD WITH ISSUER	Y	M	Y	M

6. PERSONAL REFERENCES - Provide two (2) references for HD Faculty to consult as and when required.

NAME OF REFERENCE :
COMPANY/INSTITUTION NAME:
RELATION TO REFERENCE:
COUNTRY:
CONTACT PARTICULARS:	tel. no.:	e-mail address:

NAME OF REFERENCE :
COMPANY/INSTITUTION NAME:
RELATION TO REFERENCE:
COUNTRY:
CONTACT PARTICULARS:	tel. no.:	e-mail address: