---

NONE OF THE SECURITIES TO WHICH THIS AGREEMENT RELATES HAVE BEEN REGISTERED UNDER THE UNITED STATES SECURITIES ACT OF 1933, AS AMENDED (THE "1933 ACT"), OR ANY U.S. STATE SECURITIES LAWS, AND, UNLESS SO REGISTERED, NONE MAY BE OFFERED OR SOLD,
DIRECTLY OR INDIRECTLY, IN THE UNITED STATES OR TO U.S. PERSONS (AS DEFINED HEREIN) EXCEPT IN ACCORDANCE WITH THE PROVISIONS OF REGULATION S UNDER THE 1933 ACT, PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE 1933 ACT, OR PURSUANT TO AN
AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE 1933 ACT AND IN EACH CASE ONLY IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS.  IN ADDITION, HEDGING TRANSACTIONS INVOLVING THE SECURITIES MAY
NOT BE CONDUCTED UNLESS IN COMPLIANCE WITH THE 1933 ACT.

UNLESS PERMITTED UNDER SECURITIES LEGISLATION, THE HOLDER OF THE SECURITIES MUST NOT TRADE THE SECURITIES BEFORE THE DATE WHICH IS FOUR MONTHS FROM THE DATE OF THE ISSUANCE OF THE WARRANTS.

WARRANT ISSUANCE AGREEMENT

This Warrant Issuance Agreement is dated for reference December 20, 2006,

Between:

> Brockton Capital Corp.
>       Suite 604  750 West Pender Street
>       Vancouver, BC V6C 2T7
>     (the "Company")

And:

> ________________________________
>     (the "Holder")

WHEREAS:

|A. | The Company is engaged in the business of the identification and evaluation of investment opportunities and the acquisition of and the participation therein;                                                                                                                                                                                                  
|-- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
|   |                                                                                                                                                                                                                                                                                                                                                                
|B. | The Holder has experience and expertise in respect of the identification and evaluation of oil and gas exploration and development projects;                                                                                                                                                                                                                   
|   |                                                                                                                                                                                                                                                                                                                                                                
|C. | The Company desires that the Holder identify and evaluate potential oil and gas exploration and development projects and deliver those with a reasonable potential for economic value to the Company, and the Holder has so agreed;
and                                                                                                                        
|   |                                                                                                                                                                                                                                                                                                                                                                
|D. | In consideration of the Holder's efforts in identifying, evaluating and possibly delivering potential oil and gas exploration and development projects to the Company, the Company desires to issue to the Holder warrants to purchase
common shares without par value in the capital of the Company on the terms and subject to the conditions herein set out.

NOW THEREFORE THIS AGREEMENT witnesses that in consideration of the premises and the mutual covenants and agreements herein set forth and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties
hereto agree as follows:

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- 2 -

1.ISSUANCE OF THE WARRANTS

1.1          
  The Company hereby issues to the Holder ____________ warrants (the "Warrants")
  to purchase from the Company _____________ common shares without par value in
  the capital of the Company (the "Common Shares") at an exercise price
  of US$0.10 per Warrant. The Warrants and the Common Shares are collectively
  referred to in this Agreement as the "Securities".

2.WARRANT CERTIFICATES

2.1           The
  Company shall issue to the Holder a warrant certificate (the "Warrant Certificate")
  representing the Warrants in the form attached as Schedule "A" hereto, with
  such appropriate insertions, omissions, substitutions and other variations as
  required or permitted by this Agreement.

3.EXERCISE OF WARRANTS

3.1Maturity.
  The Warrants shall only be exercisable by the Holder after the Holder delivers
  to the Company an oil or gas exploration or development project that has, in
  the reasonable opinion of the Company, an economic value to the Company of at
  least US$9,000,000 (at the time of delivery and without including any value
  for the Warrants) (an "Approved Project").

3.2
  Cash Exercise. The Holder may effect a cash exercise of the Warrants
  by surrendering to the Company the Warrant Certificate, together with a Subscription
  in the form of Schedule "A" attached thereto, duly executed by the Holder, at
  any time prior to the Expiration Date (as hereinafter defined), at the Company's
  principal office, accompanied by payment in cash, by certified or official bank
  check or wire transfer payable to the order of the Company in the amount of
  the Exercise Price (as adjusted as hereinafter provided) multiplied by the number
  of Common Shares that are the subject of the Holder's Warrants (as adjusted
  as hereinafter provided) (the "Aggregate Price").

3.3
  Cashless Exercise. The Holder may effect a cashless exercise of the Warrants
  by surrendering to the Company the Warrant Certificate, together with a duly
  executed Subscription in the form of Schedule "B" attached thereto, duly executed
  by the Holder, at any time prior to the Expiration Date, at the Company's principal
  office, in which case no payment of cash shall be required. Upon such cashless
  exercise, the number of Common Shares to be acquired by the Holder shall be
  the product of the number of Common Shares that are the subject of the Holder's
  Warrants multiplied by the amount, if any, by which the then Fair Value (as
  hereinafter defined) of the Common Shares exceeds the Exercise Price divided
  by the then per share Fair Value. The "Fair Value" shall mean the last
  reported sales price on the principal market on which the Common Shares are
  listed or quoted on the trading day immediately prior to the day on which the
  Holder notifies the Company of its exercise of the Warrants. Notwithstanding
  the foregoing, if there is no last reported sales price on the trading day immediately
  prior to the day on which the Holder notifies the Company of its exercise of
  the Warrants on a cashless basis, then Fair Value shall be determined as of
  the latest day prior to such exercise day for which such last reported sales
  price is available, unless such securities have not been traded on an exchange
  or in the over-the-counter market for 30 or more days immediately prior to such
  exercise day, in which case the Fair Value shall be determined in good faith
  by the Company's board of directors and if the Holder fails to agree with such
  determination, an independent public accounting firm or a valuation firm of
  national standing selected and engaged by the Holder and reasonably acceptable
  to the Company; provided, however, that in the event the determination by the
  accounting or valuation firm shall be more than 5% greater than the determination
  of the Company's board of directors, the expenses associated with such determination
  shall be borne by the Company.

3.4Partial
  Exercise.The Warrants may also be exercised from time to time in part by
  surrendering the Warrant Certificate in the manner specified in Section 3.2,
  with appropriate adjustments to the Aggregate Price payable and the number of
  Common Shares to be received. Upon a partial exercise, the Company, at its expense,
  shall issue to the Holder a new Warrant Certificate for the number of Common
  Shares for which the Warrant Certificate shall not have been exercised, issued
  in the name of Holder.

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- 3 -

3.5
  Issuance of Certificates. Upon exercise of the Warrants, the Company
  shall issue certificates representing the Common Shares within five business
  days without charge to the Holder including, without limitation, any tax that
  may be payable in respect of the issuance thereof, and such certificates shall
  be issued in the name of the Holder.

3.6Fractional
  Shares. In no event shall any fractional share of the Common Shares be issued
  upon any exercise of the Warrants. If, upon exercise of the Warrants as an entirety,
  the Holder would, except as provided in this Section 3.6, be entitled to receive
  a fractional share of the Common Shares, then the Company shall pay in lieu
  thereof, the Fair Value of such fractional share in cash.

3.7Reserved
  Shares; Valid Issuance. The Company shall all times from and after the date
  hereof reserve and keep available such number of its Common Shares, free from
  all pre-emptive or similar rights therein, as shall be sufficient to permit
  the exercise of the Warrants in full into the Common Shares upon such exercise.
  The Company further covenants that such shares as may be issued pursuant to
  such exercise shall, upon issuance, be duly and validly issued, fully paid and
  non-assessable and free from all taxes, liens and charges with respect to the
  issuance thereof.

3.8Expiration
  Date. The Warrants shall expire on the close of business on December 21,
  2007 unless the Holder delivers an Approved Project which is accepted by the
  Company then the Warrants shall expire on the close of business on the date
  which is six months after the date of acceptance of the Approved Project (the
  "Expiration Date"), and shall be void thereafter.

4.EXERCISE PRICE ADJUSTMENTS

4.1
  Adjustment for Stock Splits and Combinations. If the Company shall at
  any time or from time to time after the date of original issuance of the Warrants
  (the "Date of Original Issue") effect a subdivision or reverse stock
  split of the outstanding Common Shares, the Exercise Price in effect immediately
  before that subdivision shall be proportionately decreased, and, conversely,
  the Exercise Price in effect immediately before the reverse stock split shall
  be proportionately increased. Any adjustment under this Section 4.1 shall become
  effective at the close of business on the date the reverse stock split or subdivision
  becomes effective.

4.2
  Adjustment for Common Share Dividends and Distributions. If the Company
  at any time or from time to time after the Date of Original Issue issues or
  fixes a record date for the determination of holders of the Common Shares entitled
  to receive a dividend or other distribution payable solely in additional Common
  Shares, the Exercise Price that is then in effect shall be decreased as of the
  time of such issuance or, in the event such record date is fixed, as of the
  close of business on such record date, by multiplying the Exercise Price by
  a fraction: (a) the numerator of which is the total number of Common Shares
  issued and outstanding immediately prior to the time of such issuance or the
  close of business on such record date, and (b) the denominator of which is the
  sum of the total number of Common Shares issued and outstanding immediately
  prior to the time of such issuance or the close of business on such record date
  plus the number of Common Shares issuable in payment of such dividend or distribution;
  provided, however, that if such record date is fixed and such dividend is not
  fully paid or if such distribution is not fully made on the date fixed therefor,
  the Exercise Price shall be recomputed accordingly as of the close of business
  on such record date and thereafter the Exercise Price shall be adjusted pursuant
  to this Section 4.2 to reflect the actual payment of such dividend or distribution.

4.3
  Adjustments for Other Dividends and Distributions. If the Company at
  any time or from time to time after the Date of Original Issue issues, or fixes
  a record date for the determination of holders of Common Shares entitled to
  receive, a dividend or other distribution payable in securities of the Company
  other than Common Shares or in other property, in each such event provision
  shall be made so that the Holder shall receive upon conversion hereof, in addition
  to the number of Common Shares receivable hereupon, the amount of securities
  of the Company or other property which such Holder would have received had the
  Warrants been exercised for Common Shares on the date of such event and had
  it thereafter, during the period from the date of such event to and including
  the exercise date, retained such securities or other property receivable by
  it as aforesaid during such period, subject to all other adjustments called
  for during such period under this Section 4.3 with respect to the rights of
  the Holder or with respect to such other securities or other property by their
  terms. As used herein, the term "other property" does not include cash.

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- 4 -

4.4
  Adjustment for Reclassification, Exchange and Substitution. If at any
  time or from time to time after the Date of Original Issue, the Common Shares
  issuable upon the conversion of the Warrants is changed into the same or a different
  number of shares of any class or series of stock, whether by recapitalization,
  reclassification or otherwise (other than a subdivision or combination of shares
  or stock dividend or a reorganization, merger, consolidation or sale of assets
  provided for elsewhere in this Section 4.4), then in any such event the Holder
  shall have the right thereafter to exercise the Warrants for the kind and amount
  of stock and other securities and property receivable upon such recapitalization,
  reclassification or other change by holders of the number of Common Shares into
  which the Warrants could have been converted immediately prior to such recapitalization,
  reclassification or change, all subject to further adjustment as provided herein
  or with respect to such other securities or property by the terms thereof.

4.5
  Adjustment for Reorganization, Merger or Consolidation. In case of any
  reorganization of the Company or consolidation of the Company with, or merger
  of the Company with, or merger of the Company into, another entity (other than
  a reorganization, consolidation or merger which does not result in any reclassification
  or change in the terms of the outstanding Common Shares), the entity formed
  by such reorganization, consolidation or merger shall execute and deliver to
  the Holder a supplemental agreement to this Agreement providing that the Holder
  shall have the right thereafter (until the expiration of such the Warrants)
  to receive, upon exercise of such Warrants, the kind and amount of securities
  and property receivable upon such reorganization, consolidation or merger, by
  a holder of the number of Common Shares for which such Warrants might have been
  exercised immediately prior to such reorganization, consolidation or merger.
  Such supplemental agreement shall provide for adjustments which shall be identical
  to the adjustments provided in this Section 4.5 and such other rights of the
  Common Shares as provided in the Companys Articles, as amended from time
  to time. The Company shall not effect any such reorganization, consolidation
  or merger unless, prior to or simultaneously with the consummation thereof,
  the successor entity (if other than the Company) resulting from such reorganization,
  consolidation or merger shall assume, by written instrument executed and delivered
  to the Holder, the obligation to deliver to the Holder, such shares of stock,
  securities, or assets as, in accordance with the foregoing provisions, the Holder
  may be entitled to purchase, and to perform the other obligations of the Company
  under this Agreement. The above provisions of this Section 4.5 shall similarly
  apply to successive reorganizations, consolidations or mergers.

4.6
  Certificate of Adjustment. In each case of an adjustment or readjustment
  of the Exercise Price for the number of Common Shares or other securities issuable
  upon conversion of the Warrants, the Company, at its own expense, shall cause
  its Secretary or Treasurer to compute such adjustment or readjustment in accordance
  with the provisions hereof and prepare a certificate showing such adjustment
  or readjustment, and shall mail such certificate, by first class mail, postage
  prepaid, to the Holder at the Holders address as shown on page 10 hereof,
  or such other address as the Holder may designate by Notice to the Company.
  The certificate shall set forth such adjustment or readjustment, showing in
  detail the facts upon which such adjustment or readjustment is based. No adjustment
  in the Exercise Price shall be required to be made unless it would result in
  an increase or decrease of at least one cent, but any adjustments not made because
  of this sentence shall be carried forward and taken into account in any subsequent
  adjustment otherwise required hereunder.

4.7
  Notices of Record Date. Upon: (i) the establishment by the Company of
  a record of the holders of any class of securities for the purpose of determining
  the holders thereof who are entitled to receive any dividend or other distribution;
  or (ii) any capital reorganization of the Company, any reclassification or recapitalization
  of the share capital of the Company, any merger or consolidation of the Company
  with or into any other company, or any transfer of all or substantially all
  the assets of the Company to any other person or any voluntary or involuntary
  dissolution, liquidation or winding up of the Company, the Company shall mail
  to the Holder at least 20 days prior to the record date specified therein a
  notice specifying: (A) the date on which any such record is to be taken for
  the purpose of such dividend or distribution and a description of such dividend
  or distribution, (B) the date on which any such reorganization, reclassification,
  transfer, consolidation, merger, dissolution, liquidation or winding up is expected
  to become effective, and (C) the date, if any, that is to be fixed as to when
  the holders of record of Common Shares (or other securities) shall be entitled
  to exchange their Common Shares (or other securities) for securities or other
  property deliverable upon such reorganization, reclassification transfer, consolidation,
  merger, dissolution, liquidation or winding up.

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- 5 -

5.TRANSFERS; LOST SHARE CERTIFICATES

5.1
  Transfers. The Warrants may not be transferred by the Holder.

5.2
  Lost Warrants. Upon receipt by the Company of evidence reasonably satisfactory
  to it of the loss, theft, destruction or mutilation of any Warrant Certificate,
  and, in case of loss, theft or destruction, of indemnity or security reasonably
  satisfactory to it, and reimbursement to the Company of all reasonable expenses
  incidental thereto, and upon surrender and cancellation of the Warrants, if
  mutilated, the Company shall make and deliver a new Warrant Certificate of like
  tenor, in lieu thereof.

6.ACKNOWLEDGEMENTS OF THE HOLDER

6.1
  The Holder acknowledges and agrees that:

| | (a) | none of the Securities have been registered under
        the Securities Act of 1933, as amended (the "1933 Act"), or under
        any state securities or "blue sky" laws of any state of the United States,
        and are being offered only in a transaction not involving any public offering
        within the meaning of the 1933 Act, and, unless so registered, may not
        be offered or sold in the United States or to U.S. Persons (as defined
        herein), except pursuant to an effective registration statement under
        the 1933 Act, or pursuant to an exemption from, or in a transaction not
        subject to, the registration requirements of the 1933 Act, and in each
        case only in accordance with applicable state and provincial securities
        laws;
| | --- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| | (b) | the Company shall refuse to register any transfer
        of the Securities not made in accordance with the provisions of Regulation
        S, pursuant to an effective registration statement under the 1933 Act
        or pursuant to an available exemption from, or in a transaction not subject
        to, the registration requirements of the 1933 Act;                                                                                                                                                                                                                                                                                                                                                                                                                                            
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| | (c) | by completing the questionnaires in the form attached
        hereto as Schedule "B" and Schedule "C" respectively (collectively, the
        "Questionnaires"), the Holder is representing and warranting that
        it satisfies one of the categories of registration and prospectus exemptions
        provided in National Instrument 45-106 adopted by the British Columbia
        Securities Commission and as an accredited investor as that term is defined
        in Regulation D of the 1933 Act;                                                                                                                                                                                                                                                                                             
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| | (d) | the Company is entitled to rely on the representations
        and warranties and the statements and answers of the Holder contained
        in this Agreement and the Questionnaires and the Holder shall hold harmless
        the Company from any loss or damage it may suffer as a result of the Holders
        failure to correctly complete this Agreement and the Questionnaires;                                                                                                                                                                                                                                                                                                                                                                                                                  
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| | (e) | the Company has advised the Holder that the Company
        is relying on an exemption from the requirements to provide the Holder
        with a prospectus and to sell the Warrant Shares through a person registered
        to sell securities under the Securities Act(British Columbia)
        (the "BC Act") and, as a consequence of acquiring the Warrant Shares
        pursuant to this exemption, certain protections, rights and remedies provided
        by the BC Act, including statutory rights of rescission or damages, shall
        not be available to the Holder; and                                                                                                                                                                                                               
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| | (f) | that any resale of the Securities shall be subject
        to resale restrictions contained in the securities legislation applicable
        to the Holder or proposed transferee. The Holder acknowledges that the
        Securities have not been registered under the 1933 Act or the securities
        laws of any state of the United States. The Securities may not be offered
        or sold in the United States unless registered in accordance with federal
        securities laws and all applicable state securities laws or exemptions
        from such registration requirements are available.                                                                                                                                                                                           

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7.REPRESENTATIONS, WARRANTIES AND COVENANTS OF THE HOLDER

7.1
  The Holder hereby represents and warrants to and covenants with the Company
  (which representations, warranties and covenants shall survive the closing date)
  that:

| | (a) | the Holder:                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
| | --- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     | (i)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     | (ii)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     | (iii)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     | (iv)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| | (b) | the Holder is acquiring the Securities as
        principal for investment only and not with a view to, or for, resale,
        distribution or fractionalization thereof, in whole or in part, and, in
        particular, it has no intention to distribute either directly or indirectly
        any of the Securities in the United States or to U.S. Persons (as defined
        herein);                                                                                       
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| | (c) | the Holder has the legal capacity and competence
        to enter into and execute this Agreement and to take all actions required
        pursuant hereto and, the Holder is duly incorporated and validly subsisting
        under the laws of its jurisdiction of incorporation and all necessary
        approvals by its directors, shareholders and others have been obtained
        to authorize execution and performance of this Agreement on behalf of
        the Holder;
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| | (d) | the entering into of this Agreement and
        the transactions contemplated hereby do not result in the violation of
        any of the terms and provisions of any law applicable to, or, if applicable,
        the constating documents of, the Holder, or of any agreement, written
        or oral, to which the Holder may be a party or by which the Holder is
        or may be bound;                                                                                     
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
| | (e) | the Holder has duly executed and delivered
        this Agreement and it constitutes a valid and binding agreement of the
        Holder enforceable against the Holder;                                                                                                                                                                                                                                                                                                             

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- 7 -

| | (f) | the Holder has received and carefully read
        this Agreement;                                                                                                                                                                                                                                                                                                                                                                                                                                           
| | --- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| | (g) | the Holder understands and agrees that the
        Company and others shall rely upon the truth and accuracy of the acknowledgements,
        representations, warranties, covenants and agreements contained in this
        Agreement and the Questionnaires, and agrees that if any of such acknowledgements,
        representations and agreements are no longer accurate or have been breached,
        the Holder shall promptly notify the Company;                                                  
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| | (h) | the Holder is not aware of any advertisement
        of any of the Securities and is not acquiring the Securities as a result
        of any form of general solicitation or general advertising including advertisements,
        articles, notices or other communications published in any newspaper,
        magazine or similar media or broadcast over radio or television, or any
        seminar or meeting whose attendees have been invited by general solicitation
        or general advertising;
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| | (i) | no person has made to the Holder any written
        or oral representations:                                                                                                                                                                                                                                                                                                                                                                                                                                
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| |     | (i)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| |     | (ii)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| |     | (iii)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| |     | (iv)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| | (j) | the Holder acknowledges and agrees that
        the Company shall not consider its subscription for acceptance unless
        the undersigned provides to the Company, along with an executed copy of
        this Agreement:                                                                                                                                                                                                                                                                                
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| |     | (i)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
| |     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
| |     | (ii)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         

7.2
  In this Agreement, the term "U.S. Person" shall have the meaning ascribed
  thereto in Regulation S promulgated under the 1933 Act and for the purpose of
  the Agreement includes any person in the United States.

8.LEGENDING AND REGISTRATION OF SUBJECT COMMON SHARES

8.1The
  Holder hereby acknowledges that upon the issuance thereof, and until such time
  as the same is no longer required under the applicable securities laws and regulations,
  the certificates representing any of the Common Shares issued upon the exercise
  of the Warrants hereunder shall bear a legend in substantially the following
  form:

> NONE OF THE SECURITIES REPRESENTED HEREBY HAVE BEEN
>         REGISTERED UNDER THE UNITED STATES SECURITIES ACT OF 1933, AS AMENDED
>         (THE "1933 ACT"), OR ANY U.S. STATE SECURITIES LAWS, AND, UNLESS SO REGISTERED,
>         MAY NOT BE OFFERED OR SOLD, DIRECTLY OR INDIRECTLY, IN THE UNITED STATES
>         (AS DEFINED HEREIN) OR TO U.S. PERSONS EXCEPT IN ACCORDANCE WITH THE PROVISIONS
>         OF REGULATION S UNDER THE 1933 ACT, PURSUANT TO AN EFFECTIVE REGISTRATION
>         STATEMENT UNDER THE 1933 ACT, OR PURSUANT TO AN AVAILABLE EXEMPTION

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> - 8 -
>   FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION
>         REQUIREMENTS OF THE 1933 ACT AND IN EACH CASE ONLY IN ACCORDANCE WITH
>         APPLICABLE STATE SECURITIES LAWS. IN ADDITION, HEDGING TRANSACTIONS INVOLVING
>         THE SECURITIES MAY NOT BE CONDUCTED UNLESS IN COMPLIANCE WITH THE 1933
>         ACT. "UNITED STATES" AND "U.S. PERSON" ARE AS DEFINED BY REGULATION S
>         UNDER THE 1933 ACT.
>       UNLESS PERMITTED UNDER SECURITIES LEGISLATION, THE HOLDER
>         OF THE SECURITIES MUST NOT TRADE THE SECURITIES BEFORE THE DATE WHICH
>         IS FOUR MONTHS FROM THE DATE OF THE ISSUANCE OF THE WARRANTS.

8.2
  The Holder hereby acknowledges and agrees to the Company making a notation on
  its records or giving instructions to the registrar and transfer agent of the
  Company in order to implement the restrictions on transfer set forth and described
  in this Agreement.

9.COSTS

9.1
  The Holder acknowledges and agrees that all costs and expenses incurred by the
  Holder (including any fees and disbursements of any special counsel retained
  by the Holder) relating to the purchase of the Securities shall be borne by
  the Holder.

10.GOVERNING
  LAW

10.1
  This Agreement is governed by the laws of the Province of British Columbia and
  the federal laws of Canada applicable thereto. The Holder, in its own capacity
  and, if applicable, on behalf of each beneficial purchaser for whom it is acting,
  irrevocably attorns to the exclusive jurisdiction of the courts of the Province
  of British Columbia.

11.SURVIVAL

11.1 This
  Agreement, including without limitation the representations, warranties and
  covenants contained herein, shall survive and continue in full force and effect
  and be binding upon the parties hereto notwithstanding the completion of the
  purchase of the Securities by the Holder pursuant hereto.

12.ASSIGNMENT
  AND TRANSFER

12.1
  Subject to compliance with applicable federal, state and provincial securities
  laws, this Agreement and the Warrants may be transferred by the Holder with
  respect to any or all of the shares purchasable hereunder. Upon surrender of
  the Warrants to the Company, together with the assignment notice duly executed,
  for transfer of the Warrants as an entirety by the Holder, the Company shall
  issue new warrants of the same denomination to the assignee. Upon surrender
  of the Warrants to the Company, together with the assignment properly endorsed,
  by the Holder for transfer with respect to a portion of the Common Shares purchasable
  thereunder, the Company shall issue new warrants to the assignee, in such denomination
  as shall be requested by the Holder hereof, and shall issue to such Holder new
  warrants covering the number of Common Shares in respect of which the Warrant
  shall not have been transferred.

13.SEVERABILITY

13.1The
  invalidity or unenforceability of any particular provision of this Agreement
  shall not affect or limit the validity or enforceability of the remaining provisions
  of this Agreement.

---

- 9 -

14.ENTIRE AGREEMENT

14.1
  Except as expressly provided in this Agreement and in the agreements, instruments
  and other documents contemplated or provided for herein, this Agreement contains
  the entire agreement between the parties with respect to the subject matter
  hereof and there are no other terms, conditions, representations or warranties,
  whether expressed, implied, oral or written, by statute or common law, by the
  Company or by anyone else.

15.NOTICES

15.1 All notices and other communications hereunder shall be in writing and shall be deemed to have been duly given if mailed or transmitted by any standard form of telecommunication. Notices to the Holder shall be directed to the address on page 10
hereof, or such other address as the Holder may designate by Notice to the Company, and notices to the Company shall be directed to it at the first page of this Agreement.

16.COUNTERPARTS
  AND ELECTRONIC MEANS

16.1
  This Agreement may be executed in any number of counterparts, each of which,
  when so executed and delivered, shall constitute an original and all of which
  together shall constitute one instrument. Delivery of an executed copy of this
  Agreement by electronic facsimile transmission or other means of electronic
  communication capable of producing a printed copy shall be deemed to be execution
  and delivery of this Agreement as of the date hereinafter set forth.

[Remainder of this page intentionally left blank; signature
  page to follow]

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- 10 -

IN WITNESS WHEREOFthe Holder has duly executed this
Agreement as of the date hereinafter set forth.

| |                                            
| | -------------------------------------------
| | (Name  Please type or print)              
| |                                            
| | (Signature and, if applicable, Office)     
| |                                            
| | (Address)                                  
| |                                            
| | (City, province/state, and postal/zip code)
| |                                            
| | (Country)                                  
| |                                            
| | (Fax number)                               

ACCEPTANCE

The foregoing is acknowledged, accepted and agreed to this day
  of December, 2006.

| | BROCKTON CAPITAL CORP.
| | ----------------------
| |                       
| |                       
| | Per:                  
| |                       

---

SCHEDULE A

[NTD: Insert Form of Warrant Certificate]

---

SCHEDULE B

ALBERTA AND BRITISH COLUMBIA QUESTIONNAIRE

All capitalized terms herein, unless otherwise defined, have the meanings ascribed thereto in the Agreement.

The purpose of the Questionnaire is to assure the Company that the Holder shall meet certain requirements of National Instrument 45-106 ("NI 45-106").  The Company shall rely on the information contained in this Questionnaire for the purposes
of such determination.

The Holder covenants, represents and warrants to the Company that:

| | 1. | the Holder has such knowledge and experience
        in financial and business matters as to be capable of evaluating the merits
        and risks of the transactions detailed in the Agreement and the Holder
        is able to bear the economic risk of loss arising from such transactions;
| | -- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
| |    |                                                                                                                                                                                                                                                                                                  
| | 2. | the Holder is (tick one or more of the
        following boxes):                                                                                                                                                                                                                                 
| |    |                                                                                                                                                                                                                                                                                                  
| |    | (A)                                                                                                                                                                                                                                                                                              
| |    |                                                                                                                                                                                                                                                                                                  
| |    | (B)                                                                                                                                                                                                                                                                                              
| |    |                                                                                                                                                                                                                                                                                                  
| |    | (C)                                                                                                                                                                                                                                                                                              
| |    |                                                                                                                                                                                                                                                                                                  
| |    | (D)                                                                                                                                                                                                                                                                                              
| |    |                                                                                                                                                                                                                                                                                                  
| |    | (E)                                                                                                                                                                                                                                                                                              
| |    |                                                                                                                                                                                                                                                                                                  
| |    | (F)                                                                                                                                                                                                                                                                                              
| |    |                                                                                                                                                                                                                                                                                                  
| |    | (G)                                                                                                                                                                                                                                                                                              
| |    |                                                                                                                                                                                                                                                                                                  
| |    | (H)                                                                                                                                                                                                                                                                                              
| |    |                                                                                                                                                                                                                                                                                                  
| |    | (I)                                                                                                                                                                                                                                                                                              
| |    |                                                                                                                                                                                                                                                                                                  
| | 3. | if the Holder has checked box B, C, D, E,
        G or H in paragraph 3 above, the director, executive officer, founder
        or control person of the Company with whom the undersigned has the relationship
        is:                                                                      

(Instructions to the Holder: fill
  in the name of each director, executive officer, founder and control person
  which you have the above-mentioned relationship with. If you have checked

---

B-2

| |    | box G or H, also indicate which of A to F describes
        the securityholders, directors, trustees or beneficiaries which qualify
        you as box G or H and provide the names of those individuals. Please attach
        a separate page if necessary).
| | -- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
| |    |                                                                                                                                                                                                                                                               
| | 4. | if the Holder has ticked box F in Section 2 above, the
        Holder satisfies one or more of the categories of "accredited investor"
        (as that term is defined in NI 45-106) indicated below (please check the
        appropriate box):             

| |  | [ ] | (a) a Canadian financial institution as defined in National
      Instrument 14-101, or an authorized foreign bank listed in Schedule III
      of the Bank Act(Canada);                                                                                                                                                                                                                            
| |  | --- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (b) the Business Development Bank of Canada incorporated under
      the Business Development Bank Act(Canada);                                                                                                                                                                                                                                                                                     
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (c) a subsidiary of any person referred to in any of the foregoing
      categories, if the person owns all of the voting securities of the subsidiary,
      except the voting securities required by law to be owned by directors of
      that subsidiary;                                                                                                                                       
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (d) an individual registered or formerly registered under securities
      legislation in a jurisdiction of Canada, as a representative of a person
      or company registered under securities legislation in a jurisdiction of
      Canada, as an adviser or dealer, other than a limited market dealer registered
      under the Securities Act(Ontario) or the Securities Act (Newfoundland);
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (e) an individual registered or formerly registered under the
      securities legislation of a jurisdiction of Canada as a representative of
      a person referred to in paragraph (d);                                                                                                                                                                                                          
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (f) the government of Canada or a province, or any crown corporation
      or agency of the government of Canada or a province;                                                                                                                                                                                                                                                                     
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (g) a municipality, public board or commission in Canada and
      a metropolitan community, school board, the Comite de gestion de la taxe
      scholaire de lile de Montreal or an intermunicipal management board
      in Québec;                                                                                                                                                             
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (h) a national, federal, state, provincial, territorial or
      municipal government of or in any foreign jurisdiction, or any agency thereof;                                                                                                                                                                                                                                                     
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (i) a pension fund that is regulated by either the Office of
      the Superintendent of Financial Institutions (Canada) or a pension commission
      or similar regulatory authority of a jurisdiction of Canada;                                                                                                                                                                                 
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (j) an individual who either alone or with a spouse beneficially
      owns, directly or indirectly, financial assets (as defined in NI 45-106)
      having an aggregate realizable value that, before taxes but net of any related
      liabilities, exceeds CDN$1,000,000;                                                                                                                      
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (k) an individual whose net income before taxes exceeded CDN$200,000
      in each of the two more recent calendar years or whose net income before
      taxes combined with that of a spouse exceeded $300,000 in each of those
      years and who, in either case, reasonably expects to exceed that net income
      level in the current calendar year;                                       
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [ ] | (l) an individual who, either alone or with a spouse, has net
      assets of at least CDN $5,000,000;                                                                                                                                                                                                                                                                                              
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                     
| |  | [x] | (m) a person, other than an individual or investment fund,
      that had net assets of at least CDN$5,000,000 as reflected on its most recently
      prepared financial statements;                                                                                                                                                                                                               

---

B-3

| |  | [ ] | (n) an investment fund that distributes it securities
        only to persons that are accredited investors at the time of distribution,
        a person that acquires or acquired a minimum of CDN$150,000 of value
        in securities, or a person that acquires or acquired securities under
        Sections 2.18 or 2.19 of NI 45-106;                                                                 
| |  | --- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                                 
| |  | [ ] | (o) an investment fund that distributes or has distributed
        securities under a prospectus in a jurisdiction of Canada for which the
        regulator or, in Québec, the securities regulatory authority, has
        issued a receipt;                                                                                                                                                                  
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                                 
| |  | [ ] | (p) a trust company or trust corporation registered
        or authorized to carry on business under the Trust and Loan Companies
        Act(Canada) or under comparable legislation in a jurisdiction of
        Canada or a foreign jurisdiction, acting on behalf of a fully managed
        account managed by the trust company or trust corporation, as the case
        may be;                         
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                                 
| |  | [ ] | (q) a person acting on behalf of a fully managed account
        managed by that person, if that person (i) is registered or authorized
        to carry on business as an adviser or the equivalent under the securities
        legislation of a jurisdiction of Canada or a foreign jurisdiction, and
        (ii) in Ontario, is purchasing a security that is not a security of an
        investment fund;
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                                 
| |  | [ ] | (r) a registered charity under the Income Tax Act(Canada) that, in regard to the trade, has obtained advice from an
        eligibility advisor or an advisor registered under the securities legislation
        of the jurisdiction of the registered charity to give advice on the securities
        being traded;                                                                                          
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                                 
| |  | [ ] | (s) an entity organized in a foreign jurisdiction
        that is analogous to any of the entities referred to in paragraphs (a)
        to (d) or paragraph (i) in form and function;                                                                                                                                                                                                                          
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                                 
| |  | [ ] | (t) a person in respect of which all of the owners
        of interests, direct, indirect or beneficial, except the voting securities
        required by law are persons or companies that are accredited investors;                                                                                                                                                                                           
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                                 
| |  | [ ] | (u) an investment funds that is advised by a person
        registered as an advisor or a person that is exempt from registration
        as an advisor; or                                                                                                                                                                                                                                                     
| |  |     |                                                                                                                                                                                                                                                                                                                                                                                                                 
| |  | [ ] | (v) a person that is recognized or designated by the
        securities regulatory authority or, except in Ontario and Québec,
        the regulator as (i) an accredited investor, or (ii) an exempt purchaser
        in Alberta or British Columbia after this instrument comes into force;                                                                                                                  

[Remainder of this page intentionally left blank; signature
  page to follow]

---

B-4

The Holder acknowledges and agrees that it may be required by
the Company to provide such additional documentation as may be reasonably
required by the Company and its legal counsel in determining the Holders
eligibility to acquire the Securities under relevant legislation.

IN WITNESS WHEREOF, the undersigned has executed this
Questionnaire as of the day of December, 2006.

|If an Individual:  |  | If a Corporation, Partnership or Other Entity:
|------------------ |  | ----------------------------------------------
|                   |  |                                               
|                   |  |                                               
|Signature          |  | Print or Type Name of Entity                  
|                   |  |                                               
|Print or Type Name |  | Signature of Authorized Signatory             
|                   |  |                                               
|                   |  | Type of Entity                                

---

SCHEDULE C

ACCREDITED INVESTOR QUESTIONNAIRE

All capitalized terms herein, unless otherwise defined, have the meanings ascribed thereto in the Subscription Agreement.

This Questionnaire is for use by each Subscriber who is a US person (as that term is defined Regulation S of the United States Securities Act of 1933 (the 1933 Act)) and has indicated an interest in purchasing Shares of the Company. The
purpose of this Questionnaire is to assure the Company that each Subscriber will meet the standards imposed by the 1933 Act and the appropriate exemptions of applicable state securities laws. The Company will rely on the information contained in
this Questionnaire for the purposes of such determination. The Shares will not be registered under the 1933 Act in reliance upon the exemption from registration afforded by Section 3(b) and/or Section 4(2) and Regulation D of the 1933 Act.  This
Questionnaire is not an offer of the Shares or any other securities of the Company in any state other than those specifically authorized by the Company.

All information contained in this Questionnaire will be treated as confidential. However, by signing and returning this Questionnaire, each Subscriber agrees that, if necessary, this Questionnaire may be presented to such parties as the Company
deems appropriate to establish the availability, under the 1933 Act or applicable state securities law, of exemption from registration in connection with the sale of the Shares hereunder.

The Subscriber covenants, represents and warrants to the Company
  that it satisfies one or more of the categories of Accredited Investors,
  as defined by Regulation D promulgated under the 1933 Act, as indicated below:
  (Please initial in the space provide those categories, if any, of an Accredited
  Investor which the Subscriber satisfies.)

|______ Category 1 | An organization described in Section 501(c)(3) of the United States Internal Revenue Code, a corporation, a Massachusetts or similar business trust or partnership, not formed for the specific purpose of acquiring the Shares, with
total assets in excess of US $5,000,000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
|----------------- | -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
|                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
|______ Category 2 | A natural person whose individual net worth, or joint net worth with that persons spouse, on the date of purchase exceeds US $1,000,000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
|                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
|______ Category 3 | A natural person who had an individual income in excess of US $200,000 in each of the two most recent years or joint income with that persons spouse in excess of US $300,000 in each of those years and has a
reasonable expectation of reaching the same income level in the current year.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
|                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
|______ Category 4 | A bank as defined under Section (3)(a)(2) of the 1933 Act or savings and loan association or other institution as defined in Section 3(a)(5)(A) of the 1933 Act acting in its individual or fiduciary capacity; a broker
dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934(United States); an insurance company as defined in Section 2(13) of the 1933 Act; an investment company registered under the Investment Company Act of 1940(United States) or a business development company as defined in Section 2(a)(48) of such Act; a Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301(c) or (d) of the Small Business Investment
Act of 1958(United States); a plan with total assets in excess of $5,000,000 established and maintained by a state, a political subdivision thereof, or an agency or instrumentality of a state or a political subdivision thereof, for the
benefit of its employees; an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974(United States) whose investment decisions are made by a plan fiduciary, as defined in Section 3(21) of such Act,
which is either a bank, savings and loan association, insurance company or registered investment adviser, or if the employee benefit plan has total assets in excess of $5,000,000, or, if a self-directed plan, whose investment decisions are made
solely by persons that are accredited investors.

---

C-2

|______ Category 5 | A private business development company as defined in
      Section 202(a)(22) of the                                                                                                                                                         
|----------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
|                  |                                                                                                                                                                                                                                              
|                  | Investment Advisers Act of 1940(United
      States).                                                                                                                                                                                        
|                  |                                                                                                                                                                                                                                              
|______ Category 6 | A director or executive officer of the Company.                                                                                                                                                                                              
|                  |                                                                                                                                                                                                                                              
|______ Category 7 | A trust with total assets in excess of $5,000,000, not
      formed for the specific purpose of acquiring the Shares, whose purchase is
      directed by a sophisticated person as described in Rule 506(b)(2)(ii)
      under the 1933 Act.
|                  |                                                                                                                                                                                                                                              
|______ Category 8 | An entity in which all of the equity owners satisfy the
      requirements of one or more of the foregoing
categories.                                                                                                                       

Note that prospective Subscribers claiming to satisfy one of
the above categories of Accredited Investor may be required to supply the
Company with a balance sheet, prior years federal income tax returns or other
appropriate documentation to verify and substantiate the Subscribers status as
an Accredited Investor.

If the Subscriber is an entity which initialled Category 8 in
reliance upon the Accredited Investor categories above, state the name, address,
total personal income from all sources for the previous calendar year, and the
net worth (exclusive of home, home furnishings and personal automobiles) for
each equity owner of the said entity:

|
|

The Subscriber hereby certifies that the information contained
  in this Questionnaire is complete and accurate and the Subscriber will notify
  the Company promptly of any change in any such information. If this Questionnaire
  is being completed on behalf of a corporation, partnership, trust or estate,
  the person executing on behalf of the Subscriber represents that it has the
  authority to execute and deliver this Questionnaire on behalf of such entity.

IN WITNESS WHEREOF, the undersigned has executed this
Questionnaire as of the ___ day of _______________, ________.

|If a Corporation, Partnership or Other Entity: |  | If an Individual:           
|---------------------------------------------- |  | ----------------------------
|                                               |  |                             
|                                               |  |                             
|Print or Type Name of Entity                   |  | Signature                   
|                                               |  |                             
|Signature of Authorized Signatory              |  | Print or Type Name          
|                                               |  |                             
|Type of Entity                                 |  | Social Security/Tax I.D. No.

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