EX-4.1



 Exhibit 4.1 

 

			
	(company logo can go here)	  	





 Enrolment Form 
 Brookfield Asset Management Shareholder Dividend Reinvestment Plan 
  

			
	 Please refer to the
 Plan Offering
 Circular before

enrolling
  
 Copies are available
 online at:
 www.canstockta.com
 or www.brookfield.com
	  	 To: Canadian Stock Transfer Company Inc. (“CST”)

 
 I wish to enrol in Brookfield Asset Management’s Shareholder Dividend
Reinvestment Plan (the “Plan”) in
order to reinvest q all or q 50% of cash dividends received on Brookfield Asset Management’s Class
A
Limited Voting Share (the “Shares”).
  
 By signing this form,
I request to be enrolled in the Plan, acknowledge that I have read the Plan Offering
Circular containing and describing the Plan and that my participation in the Plan will be subject to its terms and
conditions. I also acknowledge that my
enrolment in the Plan will remain in effect until I otherwise notify CST,
in writing, in accordance with the Plan.


 PLEASE
PRINT CLEARLY – To avoid delays and ensure your enrolment, please complete all fields 
  

					
	 First Shareholder Name:
  
	 	Date of Birth (DD/MM/YYYY):        
 
	 	
Occupation:                        
    
  

	 Second Shareholder Name (if applicable):
  
	 	Date of Birth (DD/MM/YYYY):
 
	 	 Occupation:

 

	 Third Shareholder Name (if applicable):
  
	 	Date of Birth (DD/MM/YYYY):
 
	 	 Occupation:

 

	
Address: (street number and name, apartment number or suite):

 



							
	 City:

 
	 	Province:           
       
	 	Postal code:          
        
	 	Daytime Telephone:         
   
(      )


					
	 S.I.N. / T.I.N.:                            

  
	 	Shareholder Account Number           
               
	 	 Shareholder Email (optional):

 


 Your Shareholder Account Number is located on your Brookfield Asset Management dividend cheque. 

 

							
	 Shareholder Signature

 
  
  
	  	 Second Shareholder Signature

(if applicable)
  

 
	  	 Third Shareholder Signature

(if applicable)
  

 
	  	 Date (DD/MM/YY)
  

 
  

	  
	  	  
	  	  
	  	  


 Please see reverse of form for instructions and additional information. 

Canadian Stock Transfer Company Inc acts as administrative agent for CIBC Mellon Trust Company 







 Instructions: 
  


	 	1.	IMPORTANT: If Shares are held by a corporation, partnership, association, agency, estate or trust, this form must be signed by a duly authorized signing officer whose
title must be provided. CST may require submission of satisfactory evidence of authority of the person executing the form. 

  

	 	2.	If Shares are jointly held, all shareholders must sign this form. 

  

	 	3.	Participation in this plan is limited to Canadian and United States residents. 


 

	 	4.	If your Shares are held in more than one account, a separate enrolment form must be completed for each account that you wish to participate in the Plan.


  

	 	5.	Non-registered beneficial holders (i.e., shareholders who hold their Shares through an intermediary, such as a financial institution, broker or other nominee) should
consult with that Intermediary to determine the procedure for participation in the Plan. 

  

	 	6.	For inquiries, please contact Canadian Stock Transfer Company Inc. at 1-800-387-0825 or inquiries@canstockta.com. 


 

	 	7.	Once completed, please return the form to: 

 Canadian Stock Transfer Company Inc. 
 P.O. Box 4229 

Station A 
 Toronto, ON M5W 0G1 
 Fax: 888-488-1416 

Note: 
 CST is soliciting this
information in compliance with the Plan and Anti-Money Laundering and Anti-Terrorist Financing legislation. All information will be held in accordance with our Privacy Policy located at http://www.canstockta.com/privacyPolicy.do