Micromem Technologies Inc.: Exhibit 99.3- Filed by newsfilecorp.com

EX-99.3 4 exhibit99-3.htm EXHIBIT 99.3 Micromem Technologies Inc.: Exhibit 99.3- Filed by newsfilecorp.com

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, 4^thFloor
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 [ ]