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DEREK OIL & GAS CORPORATION
FINANCIAL STATEMENT REQUEST FORM
Pursuant to National Instrument 51-102Continuous Disclosure Obligations of the Canadian Securities Administrators, we shall deliver our annual and interim financial statements and the Management Discussion & Analysis ("MD&A") related to such financial statements to our shareholders when they request that copies be sent to them. If you wish to receive either our annual financial statements and related MD&A or our interim financial statements and related MD&A, or both, please complete the information below and mail this form or e-mail the information on this form to us at the following address:
Derek Oil & Gas Corporation
Suite 1201 – 1111 West Hastings Street
Vancouver, BC V6E 2J3
Attention: Secretary
e-mail: info@derekoilandgas.com
I wish to receive your:
(Check one or both, as necessary)
Annual financial statements and MD&A
Interim financial statements and MD&A
which should be sent to:
______________________________________
NAME (please print)
______________________________________
ADDRESS
______________________________________
Postal of Zip Code
To use electronic methods for communication with our shareholders, we request that you provide us with your e-mail address. Please insert your e-mail address and initial and date below to indicate your consent to receive information by e-mail instead of in paper form.
I HEREBY CONSENT to receipt of information by e-mail as the following address:
___________________________________________
e-mail address
Initial:______________________________________
Date:______________________________________
