SUPPLEMENTAL MAILING LIST FORM
National Instrument 51-102 Continuous Disclosure Obligations mandates that Portage Biotech Inc. (the “Corporation”) send annually a request form to registered holders and beneficial owners of securities to enable such holders and owners to request a copy of the Corporation’s annual financial statements and related MD&A (the “Statements”), in accordance with the procedures set out in National Instruments 54-101 Communication with Beneficial Owners of Securities of a Reporting Issuer. If you wish to receive the Statements, you must complete this form and forward it to our corporate offices at the following address:
PORTAGE BIOTECH INC.
47 Avenue Road, Suite 200
Toronto, Ontario M5R 2G3
Please note that both registered holders and beneficial owners should return the form; registered holders will not automatically receive the Statements. (Registered holders are those with shares registered in their name: beneficial owners have their shares registered in an agent, broker or bank’s name).
Please put my name on your Supplemental Mailing List to receive the Statements (as indicated) of Portage Biotech Inc.
(PLEASE PRINT YOUR NAME, ADDRESS AND E-MAIL ADDRESS)
___________________ Annual Financial Statements and MD&A
___________________ Check here to receive by e-mail
(First Name and Surname)
________________________________________________________
(Number and Street) (Apartment/Suite)
________________________________________________________
(City) (Province/State) (Postal Code)
______________________________________________________
(E-mail address)
Signed: _________________________________
(Signature of Shareholder)
