Surveyor's Certificate

PDF Version - Fill & Print   (380 Kb, 1 Page)

 

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Form 13

Protected A 

Privacy Act Statement

The information you provide on this form is collected by Aboriginal Affairs and Northern Development Canada under the authority of the Northwest Territories and Nunavut Mining Regulations for the purpose of certifying that a mineral claim is free of conflict with other existing mineral claims. The information may be made available for public inspection, as prescribed by the Regulations, and will be handled in accordance with the provisions of the Privacy Act  . Individuals have the right to the protection of unauthorized disclosure of and access to their personal information that is under the control of a federal government institution. Instructions for obtaining your personal information are provided in  Info Source  , a copy of which is available at major public and academic libraries or on line.

 

Note: One claim per form unless a perimeter survey of multiple claims.

I have carefully examined the ground included in the above mentioned mineral claim(s) surveyed by me, and have otherwise made all reasonable investigation in my power to ascertain if there was any other existing claim conflicting therewith, and I certify that I have found no trace or indication and have no knowledge or information of any such claim except as follows (if none, so state; if any, give particulars):