Notice - Collection and Use of Personal Information : The personal information required under this form
is collected on behalf of and used by the securities regulatory authorities set out below for purposes of the
administration and enforcement of certain provisions of the securities legislation in British Columbia,
Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia and Newfoundland. Some of the
required information will be made public pursuant to the securities legislation in each of the jurisdictions
indicated above. Other required information will remain confidential and will not be disclosed to any
person or company except to any of the securities regulatory authorities or their authorized representatives
If you have any questions about the collection and use of this information, you may contact the securities
regulatory authority in any jurisdiction(s) in which the required information is filed, at the address(es) or
telephone number(s) set out on the back of this report.
(See instructions on the back of this
NAME OF THE REPORTING
BOX 3. NAME, ADDRESS AND TELEPHONE NUMBER
OF THE INSIDER (BLOCK LETTERS)
BOX 4. JURISDICTION(S) WHERE
THE ISSUER IS A REPORTING
ISSUER OR THE EQUIVALENT
MICROMEM TECHNOLOGIES INC.
FAMILY NAME OR CORPORATE NAME
80 DUGGAN AVE.
DD MM YY TORONTO
28 03 06 PROV
DD MM YY