A beneficial owner of Notes

Amount

Currency USD CAD

Date

A "qualified institutional buyer" within the meaning of Rule 144A(a)(1) under the U.S. Securities Act of 1933, ad amended;

A prospective investor in the Notes or other securities of Empire and not a "U.S. person" within the meaning of Rule 902(k) of Regulation S under the U.S. Securities Act of 1933, as amended; or

A security analyst

Please check the box below to confirm and agree: * I am not a competitor of Empire Communities or any of its subsidiaries or acting on behalf of such a competitor.

Name of company / entity

Name of authorized signatory

Title of authorized signatory

Email *

Closing Date

Comments