Exhibit 99.5
Gold Standard Ventures Corp.
(the “Company”)
2022 NI 51-102 Request Form
for Annual Financial Statements and Interim Financial Statements
TO REGISTERED HOLDERS AND BENEFICIAL OWNERS OF SECURITIES
National Instrument 51-102 requires that the Company send annually to the registered holders and beneficial owners of its securities (“Securityholders”) a request form to allow Securityholders to elect to receive a copy of the Company’s annual financial statements and related MD&A and/or interim financial statements and related MD&A. These documents will be available on SEDAR at www.sedar.com when filed. If you wish to receive such mailings, please complete and return this form.
Please note that a request form will be mailed each year and Securityholders must return
such form each year to receive the documents indicated above.
PLEASE RETURN TO:
Gold Standard Ventures Corp.
610 – 815 West Hastings Street
Vancouver, BC V6C 1B4
The undersigned Securityholder hereby elects to receive:
| □ | Interim Financial Statements and the related MD&A; |
and / or
| □ | Annual Financial Statements and related MD&A. |
You will not receive copies of the interim or annual financial statements of the Company (or the related MD&A) if you do not complete and return this form
I confirm that I am a: ☐ registered shareholder OR ☐ beneficial shareholder of the Company.
| Signature of Securityholder: | | | Date: | |
| Name and Title of Person Signing Above | |
| if Different From Name Above: | | |
The Canadian Securities Administrators recognizes that developments in information technology allow companies to disseminate documents to securityholders and investors in a more timely and cost efficient manner than by traditional paper methods. By providing an e-mail address, you will be deemed to be consenting to the electronic delivery to you at such e-mail address of the financial statements and MD&A in PDF format, if electronic delivery is allowed by applicable regulatory rules and policies. I understand that I am not required to consent to electronic delivery and that I will be provided with a paper copy of the financial statements and MD&A if electronic delivery of such documents by e-mail fails. This consent may be revoked or changed at any time by notification to the Company at the above address.
| E-MAIL ADDRESS (optional): | | |
