Application for Federal Crown Land

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Protected A

_____ Individual Applicants

_____ Government or Companies (Go direct to A. (2))

Privacy Act Statement

The information you provide in this document is collected under the authority of the Territorial Lands Act for the purpose of making the first step in your application for Federal Crown Lands. Information on individuals is used by Aboriginal Affairs and Northern Development Canada Land Administration employees who need to know the information in order to respond to your request. We share the information you give us with First Nations, Aboriginal groups and Inuit, Territorial and Federal Government Expert Agencies and Public Government Institutions. The personal information will be retained 10 years after the last administrative use and then transferred to Library and Archives Canada. Individuals have the right to the protection of and access to their personal information under the Privacy Act  .

Must be age of majority (19 or over) to apply.

I hereby make application to: ____

• Lease
• Lease with Purchase Option (Within Communities and Settled Land Claim Areas only)
• Licence of Occupation (Linear Development only, ie: roads, Pipelines etc.)
• Purchase (Within Communities and Settled Land Claim Areas only)
• Easement (Linear Development only, ie: Roads, Pipelines etc.)

Full Legal Name: __________________

Family Name: __________________

Given Name: __________________

Middle Name: __________________

Address/Apt./P.O. Box/Street No./Street Name: __________________

City/Town: __________________

Prov./Terr./State: __________________

Country: __________________

Postal Code/Zip Code: __________________

Email Address: __________________

Tel. No. (Home): __________________

Tel. No. (Work): __________________

Cellular No.: __________________

Facsimile No.: __________________

Occupation: __________________

Employer: __________________

Are you a Federal Employee: Yes  /  No

Do you have a partner/spouse who is a Federal Employee: Yes  /  No

• If Yes, which Federal Department and Division do they work for: __________________

Full Legal Name: __________________

Family Name: __________________

Given Name: __________________

Middle Name: __________________

Address/Apt./P.O. Box/Street No./Street Name: __________________

City/Town: __________________

Prov./Terr./State: __________________

Country: __________________

Postal Code/Zip Code: __________________

Email Address: __________________

Tel. No. (Home): __________________

Tel. No. (Work): __________________

Cellular No.: __________________

Facsimile No.: __________________

Occupation: __________________

Employer: __________________

Are you a Federal Employee: Yes  /  No

Do you have a partner/spouse who is a Federal Employee: Yes  /  No

• If Yes, which Federal Department and Division do they work: __________________

Identify tenancy type if two or more persons applying for this land: __________________

• Joint Tenancy
• Tenancy in Common

Joint Tenancy:
The primary purpose of Joint Tenancy is the right of survivorship, upon death of one joint tenant, their interest passes to the other joint tenant automatically and at length to the last survivor.

Tenancy in Common:
A form of ownership whereby each tenant (Owner or Lessee) holds an undivided interest in property. Upon the death of one of the individuals their property interest passes to their heirs.

Land Purpose: __________________

• Commercial
• Industrial
• Residential
• Other (Specify): __________________

I hereby make application to: __________

• Lease
• Lease with Purchase Option (Within Communities and Settled Land Claim Areas only)
• Licence of Occupation (Linear Development only, ie: roads, Pipelines etc.)
• Reserve (Government only)
• Purchase (Within Communities and Settled Land Claim Areas only)
• Easement (Linear Development only, ie: Roads, Pipelines etc.)
• Transfer (Government only)

Full Legal Name of Government/Company/Corporation/Association: __________________

Address/Apt./P.O. Box/Street No./Street Name: __________________

City/Town: __________________

Prov./Terr./State: __________________

Country: __________________

Postal Code/Zip Code: __________________

Contact Person for Government, Company, Corporation or Association: __________________

Email Address: __________________

Tel. No. (Home): __________________

Tel. No. (Work): __________________

Cellular No.: __________________

Facsimile No.: __________________

Address/Apt./P.O. Box/Street No./Street Name: __________________

City/Town: __________________

Prov./Terr./State: __________________

Country: __________________

Postal Code/Zip Code: __________________

General Description of Parcel (ie: hilly or flat, tree cover, soil type). If the parcel is surveyed, please indicate lot, block, group, QUAD, CLSR and LTO numbers. If unsurveyed, state size of parcel, NTS MAP Sheet Number (QUAD Number) and general location.

______________________________________________________

______________________________________________________

______________________________________________________

Provide a National Topographic System (NTS) map at a scale of 1:50,000 that indicates the following features: _______________

• Approximate location of land under application or indicate the kilometre post of road/highway, if applicable
• Proposed new access routes
• Nearby water bodies
• Use of adjacent land
• Distance to nearest community
• Co-ordinates
• Existing access if any

Indicate approximate area applied for in metres: (Metres X Metres) __________________

Indicate approximate hectare size: __________________
Hectares (metres x metres divided by 10000 = hectares)

1. Outside of Community Boundaries

*NTS Map Sheet No.: __________________

*Map or GPS Longitude and Latitude Co-ordinates: (Indicate Degrees, Minutes and Seconds)

North Latitude: __________________

West Longitude: __________________

Map or GPS UTM Co-ordinates

• Parcel Corner 1 Eastings: __________________
• Northings: __________________
• Parcel Corner 2 Eastings: __________________
• Northings: __________________
• Parcel Corner 3 Eastings: __________________
• Northings: __________________
• Parcel Corner 4 Eastings: __________________
• Northings: __________________
• Parcel Centre Point Eastings: __________________
• Northings: __________________
• GPS Map Datum (ie: NAD 83, NAD 27): __________________

2. Inside Community Boundaries (Provide Community Mapping at a scale of 1:5,000 scale or less)

*Community Name: __________________

Draw a detailed site sketch ON THE LAST PAGE OF THIS APPLICATION FORM of your proposed development. Exact dimensions of buildings are not necessary. Provide the approximate dimensions of buildings etc. shown within the parcel applied for. Your sketch must include:

• Boundaries, approximate dimensions in metres or feet
• Location of water bodies, lake front, stream bank etc.
• Location or proposed buildings and structures
• North Arrow Indicator
• Waste disposal, fuel storage, docks and breakwaters area, etc.
• Water bodies to be used for transportation and/or recreation
• Access routes, trails, paths, roads
• Scale
• Existing facilities

Measure the distance of the boundaries of the parcel of land being applied for. When locating the parcel of land applied for, it is important that the location is defined by distance measurement and possibly compass bearings in relation to some known point or land feature.

IE: Distance to an existing survey posts of other property in that area, highway survey monuments, the shorelines of water bodies (lakes, rivers, creeks) and kilometre posts.

Commercial/Industrial applications may require approval-in-principal or associated licencing from the Government of the Northwest Territories, Department of Industry, Tourism and Investment (GNWT-ITI), prior to this Department's issuing any approvals of this application. Please ensure the proper application(s) has been made and documentation (ie: Tourism Licence) is provided with your application.

Type of industrial or commercial use (Describe In detail)

______________________________________________________

______________________________________________________

______________________________________________________

Attach copy of approved licences, approval or authorizations from GNWT-ITI: ______

• Commercial: ______
• Industrial: ______
• Residential (In Communities only): ______
• Other (Please specify): __________________

Is your use: ______

• Year round or
• Seasonal

If seasonal, provide details of your seasonal activities

______________________________________________________

______________________________________________________

How many year round residents will be living at the site

Describe any existing buildings or structures currently on site and their condition. Use your sketch for illustration.

______________________________________________________

______________________________________________________

How far from the Ordinary High Water Mark are these existing improvements? (Metres)

______________________________________________________

 

Value of improvements already on the land: ___________________________

Name of Owner of Improvements: ___________________________

Describe any new planned facilities to be constructed and the methods and materials to be used.

______________________________________________________

______________________________________________________

Outline the time schedule for your construction program. Indicate approximate start and completion dates.

Start Date: (YYYYMMDD)

Completion Date: (YYYYMMDD)

Describe existing and proposed methods of access, and transportation for your project

______________________________________________________

______________________________________________________

Provide a brief description of the capital costs for your project.

______________________________________________________

Site Preparation: __________________

Materials for Initial Construction: __________________

Construction Costs: __________________

Are there any wastes produced by this use? Yes  /  No

If Yes describe the type of waste, the volume of waste and the disposal method(s) to be used.

______________________________________________________

How do you plan to dispose of:

Liquid Waste (grey water, sewage): __________________

Solid Waste: __________________

If you have specific waste treatment equipment in mind, please describe it

______________________________________________________

Are there any hazardous materials to be stored other than consumer goods? Yes/NO

If Yes, please list the type, estimated volume, quantities and storage method(s).
*Hazardous materials as defined in the Transportation of Dangerous Goods Act and Regulations.

______________________________________________________

What other general resource activities are taking place on or near your proposed project area? E.g.: Does the area involve a trap line or any mining activity? Is it an access point for resident anglers, hunters, campers, etc.? Is there a registered mineral claim on the project area?

______________________________________________________

Do you see any activity listed in your answer to the above affecting your operation, or is your operation a conflict to them? If so, how?

______________________________________________________

Do you plan on using your facilities for other than the applied for purpose? Yes  /  No

If Yes, briefly describe alternate use.

______________________________________________________

Land Application Fee ($150.00) (Except Government Agencies): ______________

GST for all Applications (Except Residential Uses): ______________

Total Fees Submitted with Application: ______________

NOTE: This application will be subject to an environmental review and consultation process. As a result of this process, if it is determined that your application must be refused, the application fees submitted with your application will not be refunded.

Individuals Signatures: __________________

I certify that the information I have given in this application is correct, to the best of my knowledge.

I hereby acknowledge and confirm that the filing of this application does not grant me any rights to take, occupy or use the land for which I have applied.

Applicant Name (Print): __________________

Applicant Signature: __________________

Date: (YYYYMMDD)

Co-applicant Name (Print): __________________

Co-applicant Signature: __________________

Date: (YYYYMMDD)

Federal or Territorial Government Officials Signatures

I certify that the information I have given in this application is correct, to the best of my knowledge.

I hereby acknowledge and confirm that the filing of this application does not grant me any rights to take, occupy or use the land for which
I have applied.

Applicant Name (Print): __________________

Applicant Signature: __________________

Date: (YYYYMMDD)

On behalf of (Federal/Territorial Government Department Name): __________________

Companies, Corporations or Associations Signatures

If your Company, Corporation or Association is in good standing at the NWT Companies Registry, please attach the Certificate of Incorporation, company current standing and signing authorities.

Certificate of Incorporation attached.: ______________

If your Company, Corporation or Association can sign legal documents without your Corporate Seal, please attach a Certified True copy or your BY-LAWS that state you can sign legal documents without your Corporate Seal.

If your Power of Attorney can sign legal documents on behalf of your Company, Corporation or Association, please attach a copy of your Power of Attorney documentation.

I certify that the information I have given in this application is correct, to the best of my knowledge.

I hereby acknowledge and confirm that the filing of this application does not grant me any rights to take, occupy or use the land for which I have applied.

Applicant Name (Print): __________________

Applicant Signature: __________________

Date: (YYYYMMDD)

On behalf of (Company, Corporation or Association Name): __________________

Date Application Received: (YYYYMMDD)

Received by: __________________

Application Checklist Completed: (YYYYMMDD)

Completed by: __________________

DRAW SKETCH OF PARCEL APPLIED FOR HERE
AS INSTRUCTED IN PART C OF THIS APPLICATION FORM

INTER 50-037F 2012-04-01