Statement of Representation Work

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Form 9

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 establishing the statement of representation work. 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.

For Office Use Only










I have done, or caused to be done, work on the following mineral claim(s):  
Amount of Fees

$
Receipt No.
Name(s) of Claim Holder(s)


Telephone Number
Mailing Address





Prospector's Licence No.(s) (Valid Licence(s) Required)

 

Mining District
 
  • NWT
  • Nunavut

Claim Sheet No.(s) (NTS)

 

Work Performed on Mineral Claim(s)

 

Type of Work Performed


Work Performed on Following Days
Work Done by


Grouping Certificate No. 
Address



Total Value of Work Performed


$
The above noted work is to be applied to renew the following claim(s) in the amounts indicated:  

Claim Tag No. Claim Name Claim Area (Acres) Cost Distribution Next Due Date
(YYYY-MM-DD)
 Excess Credit ($)
New Work ($) Existing Excess Credit ($)
             
             
             
             
             
             

I hereby certify that:
  1.  
  2. I have personal and intimate knowledge of the above noted facts; and
  3. These facts are true. 
Claim Holder or Agent's Signature


Date (YYYY-MM-DD) 

Department Use Only


Certificate:

This statement is approved as is or is approved to the value of:
$
Mining Recorder's Signature



Date (YYYY-MM-DD) 

INTER 50-009E 2012-04-01