Supplier Interest Form

Organization Information
Legal Company Name*
Home Office Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Local Office Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Website
Please attach any relevant documents or files, such as brochures

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Primary Company Representative
Company Representative Name*
Company Representative Title
Company Representative Phone Number*
Please enter a valid phone number.
Company Representative Email*
example@example.com
Ownership Information
Number of years in business
Number of employees
Does the organization have a documented health and safety management system?

YesNo
Does the organization have a documented quality management system?

YesNo
Other names the company has operated under
Ownership of Company (partnership, corporation or other). If a subsidiary of another company, name the parent company. Please indicate any subsidiaries and whether wholly owned or the percentage:
Indigenous/Local Priority Area
"Local Priority Area” means the local geographic area comprising those communities in northwestern Saskatchewan primarily impacted by the Project, and described as:
1. The area accessed by travelling north and west of the intersection of highway SK-155 beginning at, and including, the junction to highway SK-925; and
2. The communities of Descharme Lake, Clearwater River Dene Nation, La Loche, Bear Creek, Black Point, Garson Lake, Birch Narrows Dene Nation, Turnor Lake, Buffalo Narrows, Buffalo River Dene Nation, St. George’s Hill, Michel Village, and such other communities as NexGen may reasonably determine are primarily impacted by the Project from time to time.
Please indicate First Nation or Métis Region ownership of the company
Percentage of First Nation or Métis Region ownership (%)
Percentage of Indigenous workforce (%)
Please indicate which, if any, of the following Indigenous Nations you are partnered with

Clearwater River Dene Nation (CRDN),Metis Nation – Saskatchewan Northern Region 2 (MN-S NR2)Buffalo River Dene Nation (BRDN)Birch Narrows Dene Nation (BNDN)
Specify the type of partnership with the entity (revenue share, joint venture, equity stake, etc.)
Percentage ownership in partner entity (%)
Does the organization have a physical address within the Local Priority Area?

YesNo
Does the organization have an Indigenous Policy

YesNo
Please list all partnerships the organization has with Indigenous communities
Material Supplier Information
Please select the various types of products the organization can provide

Automotive PartsBearingsBuilding SuppliesCement/ShotcreteChemicalsCommunication EquipmentConveyer BeltingDrilling SuppliesElectricalElectrical CableElectric MotorsElectric Motor ServicingFastenersFittingsFuelsGasesGround SupportHeavy Equipment PartsHydraulicsIT SuppliesLubricantsLumberMRO — General SuppliesOffice ProductsPipingPlumbingPPEPower TransmissionPrinting ServicesPumpsReagentsRentalsSteel FabricationTiresValvesWater TreatmentEquipment (specify below)Other (specify below)
Equipment details (if selected)
Other details (if selected)
Service Supplier Information
Please select the various services the organization can provide

Aerial Surveying/PhotoCommunications/ITConstructionElectricalEngineeringExplorationHeavy Equipment MaintenanceLabourersMarketingMedical AidMillwrightMining LabourOffice/Professional SupportPipingRecruitmentSecurityTrainingTransportationWeldingNDE Inspection & TestingConsulting (specify below)Servicing (specify below)
Consulting details (if selected)
Servicing details (if selected)
Acknowledgement*

I acknowledge that submitting this form is an expression of interest only and does not guarantee any engagement or work with NexGen Energy Ltd. I undertstand that my information will be retained on file for consideration in future opportunities
Should be Empty:

Organization Information

Primary Company Representative

Ownership Information

Indigenous/Local Priority Area

Material Supplier Information

Service Supplier Information