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Authorization to post information

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Please print and complete the following form and sent it by mail to Geneviève Lévesque to one of these addresses: 184 Lake Promenade Toronto (Ontario) M8W 1A8 or 414 - 1800 14a Street S.W. Calgary (Alberta) T2T 6K3 I authorize you to post on the Virtual Resources Center of website www.CapitalDocumentation.ca the biography which I sent you at email info@CapitalDocumentation.ca . I also authorize you to post my photo : ___ which I sent you by email ; ___ which I am hereby sending to you by mail (please return it to me after scanning it); ___ which you can download from the following website : ________________________________ Please find herewith a cheque (made to Geneviève Lévesque) for one hundred dollars for posting my information in English in the Virtual Resources Center and/or in French in the Centre virtuel de resources. Name : ___________________________ Street : ____________________________ City : _____________________________ Province : ___________ Postal code : _____________ Email: ____________________________ Phone : _________________________ Fax : ________________________ Signed on ___________________ _________________________ (your signature)

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Last Update : 2010-05-24