Exhibit 99.3
MICROMEM TECHNOLOGIES INC.
777 Bay Street, Suite 1910, Toronto, Ontario M5G 2E4
2010 Request for Interim and /or Annual Financial Statements
In accordance with National Instrument 51-102 –Continuous Disclosure Obligations,shareholders may elect annually to have their names added to the issuer’s Supplemental Mailing List for Financial Statements with MD&A.
Please indicate your choices below and return to:
Equity Transfer & Trust Company
200 University Avenue, 4thFloor
Toronto, ON M5H 4H1
I HEREBY CERTIFY that I am a Shareholder of the Company, and as such, request that you provide me with the following:
[ ] Interim Financial Statements with MD&A
[ ] Annual Financial Statements with MD&A
PLEASE PRINT
FIRST NAME | LAST NAME |
ADDRESS |
CITY | PROVINCE/ STATE | POSTAL / ZIP CODE |
COUNTRY |
SIGNED: | |||
(Signature of Shareholder) |
THIS IS AN ADDRESS CHANGE [ ]