<SEC-DOCUMENT>0001193125-17-015374.txt : 20170123 <SEC-HEADER>0001193125-17-015374.hdr.sgml : 20170123 <ACCEPTANCE-DATETIME>20170123164302 ACCESSION NUMBER: 0001193125-17-015374 CONFORMED SUBMISSION TYPE: F-X PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20170123 DATE AS OF CHANGE: 20170123 EFFECTIVENESS DATE: 20170123 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: FORTUNA SILVER MINES INC CENTRAL INDEX KEY: 0001341335 STANDARD INDUSTRIAL CLASSIFICATION: GOLD & SILVER ORES [1040] IRS NUMBER: 000000000 STATE OF INCORPORATION: A1 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: F-X SEC ACT: 1933 Act SEC FILE NUMBER: 333-215659 FILM NUMBER: 17541435 BUSINESS ADDRESS: STREET 1: 200 BURRARD ST STREET 2: SUITE 650 CITY: VANCOUVER STATE: A1 ZIP: V6C 3L6 BUSINESS PHONE: 604-484-4085 MAIL ADDRESS: STREET 1: 200 BURRARD ST STREET 2: SUITE 650 CITY: VANCOUVER STATE: A1 ZIP: V6C 3L6 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: FORTUNA SILVER MINES INC CENTRAL INDEX KEY: 0001341335 STANDARD INDUSTRIAL CLASSIFICATION: GOLD & SILVER ORES [1040] IRS NUMBER: 000000000 STATE OF INCORPORATION: A1 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: F-X BUSINESS ADDRESS: STREET 1: 200 BURRARD ST STREET 2: SUITE 650 CITY: VANCOUVER STATE: A1 ZIP: V6C 3L6 BUSINESS PHONE: 604-484-4085 MAIL ADDRESS: STREET 1: 200 BURRARD ST STREET 2: SUITE 650 CITY: VANCOUVER STATE: A1 ZIP: V6C 3L6 </SEC-HEADER> <DOCUMENT> <TYPE>F-X <SEQUENCE>1 <FILENAME>d175700dfx.htm <DESCRIPTION>F-X <TEXT> <HTML><HEAD> <TITLE>F-X</TITLE> </HEAD> <BODY BGCOLOR="WHITE"> <P STYLE="line-height:1.0pt;margin-top:0pt;margin-bottom:0pt;border-bottom:1px solid #000000"> </P> <P STYLE="line-height:3.0pt;margin-top:0pt;margin-bottom:2pt;border-bottom:1px solid #000000"> </P> <P STYLE="margin-top:4pt; margin-bottom:0pt; font-size:18pt; font-family:Times New Roman" ALIGN="center"><B>U.S. SECURITIES AND EXCHANGE COMMISSION </B></P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:12pt; font-family:Times New Roman" ALIGN="center"><B>WASHINGTON, D.C. 20549 </B></P> <P STYLE="font-size:12pt;margin-top:0pt;margin-bottom:0pt"> </P><center> <P STYLE="line-height:6.0pt;margin-top:0pt;margin-bottom:2pt;border-bottom:1.00pt solid #000000;width:21%"> </P></center> <P STYLE="margin-top:12pt; margin-bottom:0pt; font-size:18pt; font-family:Times New Roman" ALIGN="center"><B><FONT STYLE="white-space:nowrap">FORM F-X</FONT> </B></P> <P STYLE="font-size:12pt;margin-top:0pt;margin-bottom:0pt"> </P><center> <P STYLE="line-height:6.0pt;margin-top:0pt;margin-bottom:2pt;border-bottom:1.00pt solid #000000;width:21%"> </P></center> <P STYLE="margin-top:12pt; margin-bottom:0pt; font-size:12pt; font-family:Times New Roman" ALIGN="center"><B>APPOINTMENT OF AGENT FOR SERVICE </B></P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:12pt; font-family:Times New Roman" ALIGN="center"><B>OF PROCESS AND UNDERTAKING </B></P> <P STYLE="font-size:12pt;margin-top:0pt;margin-bottom:0pt"> </P><center> <P STYLE="line-height:6.0pt;margin-top:0pt;margin-bottom:2pt;border-bottom:1.00pt solid #000000;width:21%"> </P></center> <P STYLE="font-size:12pt;margin-top:0pt;margin-bottom:0pt"> </P> <TABLE CELLSPACING="0" CELLPADDING="0" WIDTH="100%" BORDER="0" STYLE="BORDER-COLLAPSE:COLLAPSE; font-family:Times New Roman; font-size:10pt"> <TR> <TD WIDTH="3%"></TD> <TD VALIGN="bottom" WIDTH="1%"></TD> <TD WIDTH="3%"></TD> <TD VALIGN="bottom" WIDTH="1%"></TD> <TD WIDTH="31%"></TD> <TD VALIGN="bottom" WIDTH="1%"></TD> <TD WIDTH="60%"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"><B>A.</B></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">Name of issuer or person filing (“Filer”):</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top"><B>FORTUNA SILVER MINES INC.</B></TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="16"></TD> <TD HEIGHT="16" COLSPAN="2"></TD> <TD HEIGHT="16" COLSPAN="4"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"><B>B.</B></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">(1)</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">This is (check one):</TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="8"></TD> <TD HEIGHT="8" COLSPAN="2"></TD> <TD HEIGHT="8" COLSPAN="4"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">☒</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">an original filing for the Filer.</TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="8"></TD> <TD HEIGHT="8" COLSPAN="2"></TD> <TD HEIGHT="8" COLSPAN="4"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">☐</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">an amended filing for the Filer.</TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="8"></TD> <TD HEIGHT="8" COLSPAN="2"></TD> <TD HEIGHT="8" COLSPAN="4"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">(2)</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">Check the following box if you are filing the Form <FONT STYLE="white-space:nowrap">F-X</FONT> in paper in accordance with Regulation <FONT STYLE="white-space:nowrap">S-T</FONT> Rule 101(b)(9): ☐</TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="16"></TD> <TD HEIGHT="16" COLSPAN="6"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"><B>C.</B></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="5">Identify the filing in conjunction with which this Form is being filed:</TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="8"></TD> <TD HEIGHT="8" COLSPAN="4"></TD> <TD HEIGHT="8" COLSPAN="2"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">Name of registrant:</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top"><B>FORTUNA SILVER MINES INC.</B></TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="8"></TD> <TD HEIGHT="8" COLSPAN="4"></TD> <TD HEIGHT="8" COLSPAN="2"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">Form type:</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top"><B>Registration Statement on Form <FONT STYLE="white-space:nowrap">F-10</FONT></B></TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="8"></TD> <TD HEIGHT="8" COLSPAN="4"></TD> <TD HEIGHT="8" COLSPAN="2"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">File Number (if known):</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top"><B><FONT STYLE="white-space:nowrap">333-215659</FONT></B></TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="8"></TD> <TD HEIGHT="8" COLSPAN="4"></TD> <TD HEIGHT="8" COLSPAN="2"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">Filed by:</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top"><B>FORTUNA SILVER MINES INC.</B></TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="8"></TD> <TD HEIGHT="8" COLSPAN="4"></TD> <TD HEIGHT="8" COLSPAN="2"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3">Date Filed: (if filed concurrently, so indicate)</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top"> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman"><B>January 23, 2017</B></P> <P STYLE="margin-top:0pt; margin-bottom:1pt; font-size:10pt; font-family:Times New Roman"><B></B>(concurrent herewith)<B></B></P></TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="16"></TD> <TD HEIGHT="16" COLSPAN="6"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"><B>D.</B></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="5"> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman">The Filer is incorporated or organized under the laws of:</P> <P STYLE="font-size:6pt;margin-top:0pt;margin-bottom:0pt"> </P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman"><B>British Columbia, Canada</B></P> <P STYLE="font-size:6pt;margin-top:0pt;margin-bottom:0pt"> </P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman">and has its principal place of business at:</P> <P STYLE="font-size:6pt;margin-top:0pt;margin-bottom:0pt"> </P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman"><B>200 Burrard Street, Suite 650</B></P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman"><B>Vancouver, British Columbia, Canada V6C 3L6</B></P> <P STYLE="margin-top:0pt; margin-bottom:1pt; font-size:10pt; font-family:Times New Roman"><B>(604) <FONT STYLE="white-space:nowrap">484-4085</FONT></B></P></TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="16"></TD> <TD HEIGHT="16" COLSPAN="6"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"><B>E.</B></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="5"> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman">The Filer designates and appoints C T Corporation System<B> </B>(“Agent”) located at:</P> <P STYLE="font-size:6pt;margin-top:0pt;margin-bottom:0pt"> </P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman"><B>111 Eighth Avenue</B></P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman"><B>New York, New York 10011</B></P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman"><B>(212) <FONT STYLE="white-space:nowrap">894-8940</FONT></B></P> <P STYLE="font-size:6pt;margin-top:0pt;margin-bottom:0pt"> </P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman">as the agent of the Filer upon whom may be served any process, pleadings, subpoenas, or other papers in:</P> <P STYLE="font-size:6pt;margin-top:0pt;margin-bottom:0pt"> </P> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman">(a) Any investigation or administrative proceeding conducted by the Commission; and</P> <P STYLE="font-size:6pt;margin-top:0pt;margin-bottom:0pt"> </P> <P STYLE="margin-top:0pt; margin-bottom:1pt; font-size:10pt; font-family:Times New Roman">(b) Any civil suit or action brought against the Filer or to which the Filer has been joined as defendant or respondent, in any appropriate court in any place subject to the jurisdiction of any State or of the United States, or of any of its territories or possessions, or of the District of Columbia, where the investigation, proceeding or cause of action arises out of or relates to or concerns any offering made or purported to be made in connection with the securities registered or qualified by the Filer on <FONT STYLE="white-space:nowrap">Form F-10</FONT> on the date hereof or any purchases or sales of any security in connection therewith. The Filer stipulates and agrees that any such civil suit or action or administrative proceeding may be commenced by the service of process upon, and that service of an administrative subpoena shall be effected by service upon such agent for service of process, and that the service as aforesaid shall be taken and held in all courts and administrative tribunals to be valid and binding as if personal service thereof had been made.</P></TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="16"></TD> <TD HEIGHT="16" COLSPAN="6"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"><B>F.</B></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="5">The Filer stipulates and agrees to appoint a successor agent for service of process and file an amended Form <FONT STYLE="white-space:nowrap">F-X</FONT> if the Filer discharges the Agent or the Agent is unwilling or unable to accept service on behalf of the Filer at any time until six years have elapsed following the date the Filer has ceased reporting under the U.S. Securities Exchange Act of 1934. The Filer further undertakes to advise the Commission promptly of any change to the Agent’s name or address during such period by amendment of this Form, referencing the file number of the relevant form in conjunction with which the amendment is being filed.</TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="16"></TD> <TD HEIGHT="16" COLSPAN="6"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"><B>G.</B></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="5">The Filer undertakes to make available, in person or by telephone, representatives to respond to inquiries made by the Commission staff, and to furnish promptly, when requested to do so by the Commission staff, information relating to the <FONT STYLE="white-space:nowrap">Form F-10,</FONT> the securities to which the Form <FONT STYLE="white-space:nowrap">F-10</FONT> relates and the transactions in such securities.</TD></TR> </TABLE> <P STYLE="font-size:10pt;margin-top:0pt;margin-bottom:0pt"> </P> <P STYLE="line-height:1.0pt;margin-top:0pt;margin-bottom:0pt;border-bottom:1px solid #000000"> </P> <P STYLE="line-height:3.0pt;margin-top:0pt;margin-bottom:2pt;border-bottom:1px solid #000000"> </P> <p Style='page-break-before:always'> <HR SIZE="3" style="COLOR:#999999" WIDTH="100%" ALIGN="CENTER"> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman">The Filer certifies that it has duly caused this power of attorney, consent, stipulation and agreement to be signed on its behalf by the undersigned, thereunto duly authorized, in Lima, Peru on January 23, 2017. </P> <P STYLE="font-size:12pt;margin-top:0pt;margin-bottom:0pt"> </P><DIV ALIGN="right"> <TABLE CELLSPACING="0" CELLPADDING="0" WIDTH="40%" BORDER="0" STYLE="BORDER-COLLAPSE:COLLAPSE; font-family:Times New Roman; font-size:10pt"> <TR> <TD WIDTH="6%"></TD> <TD VALIGN="bottom"></TD> <TD WIDTH="12%"></TD> <TD VALIGN="bottom" WIDTH="1%"></TD> <TD WIDTH="80%"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top">By:</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3"> <P STYLE="margin-top:0pt; margin-bottom:1pt; border-bottom:1px solid #000000; font-size:10pt; font-family:Times New Roman">/s/ Jorge Ganoza Durant</P></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">Name:</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">Jorge Ganoza Durant</TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">Title:</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">President and Chief Executive Officer</TD></TR> </TABLE></DIV> <p Style='page-break-before:always'> <HR SIZE="3" style="COLOR:#999999" WIDTH="100%" ALIGN="CENTER"> <P STYLE="margin-top:0pt; margin-bottom:0pt; font-size:10pt; font-family:Times New Roman">This statement has been signed by the following person in the capacity indicated on January 23, 2017. </P> <P STYLE="font-size:12pt;margin-top:0pt;margin-bottom:0pt"> </P><DIV ALIGN="right"> <TABLE CELLSPACING="0" CELLPADDING="0" WIDTH="40%" BORDER="0" STYLE="BORDER-COLLAPSE:COLLAPSE; font-family:Times New Roman; font-size:10pt"> <TR> <TD WIDTH="6%"></TD> <TD VALIGN="bottom"></TD> <TD WIDTH="12%"></TD> <TD VALIGN="bottom" WIDTH="1%"></TD> <TD WIDTH="80%"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top" COLSPAN="5"><B>C T CORPORATION SYSTEM</B></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top" COLSPAN="5">(Agent for Service)</TD></TR> <TR STYLE="font-size:1pt"> <TD HEIGHT="16"></TD> <TD HEIGHT="16" COLSPAN="4"></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top">By:</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top" COLSPAN="3"> <P STYLE="margin-top:0pt; margin-bottom:1pt; border-bottom:1px solid #000000; font-size:10pt; font-family:Times New Roman">/s/ Candice Pignataro</P></TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">Name:</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">Candice Pignataro</TD></TR> <TR STYLE="font-family:Times New Roman; font-size:10pt"> <TD VALIGN="top"></TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">Title:</TD> <TD VALIGN="bottom"> </TD> <TD VALIGN="top">Assistant Secretary</TD></TR> </TABLE></DIV> </BODY></HTML> </TEXT> </DOCUMENT> </SEC-DOCUMENT>