Application to Record Mineral Claim(s)

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Form 3

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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.

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Submit to the Mining Recorder for the district in which the claim(s) is(are) located. 

Mining District
  • NWT 
  • Nunavut

Name(s) of person(s) who located claim(s)


Prospector's Licence No.(s)


Address(es)



Telephone Number(s)


Fax Number(s)


Claim(s) to be recorded in the name(s) of the locator(s) stated above or in the name(s) of:


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


Address(es)



Telephone Number(s)


Fax Number(s)



Claim
Tag No.		 Claim Name Date and Time at NE-1 Corner Date and Time at SE-2 Corner Date and Time at SW-3 Corner Date and Time at NW-4 Corner Date and Time completed at NE-1 Corner Claim Area (Acres) Claim Sheet No.(s) (NTS)
 

 		                
 

 		                
 

 		                
 

 		                
 

 		                
  Receipt No.

 		 Total Fees
$		 Total Claim Area


 

Statement of Applicant


I, the undersigned, hereby certify that:

  1. The required prospector’s licence(s) is(are) valid.

  2. I located or caused to be located in accordance with the Northwest Territories and Nunavut Mining Regulations the mineral claim(s) documented above, encompassing the lands described on the sketch or plan attached.

  3. Legal posts have been placed to mark the location of the claim(s) and a numbered identification tag has been fastened on each corner in accordance with the Northwest Territories and Nunavut Mining Regulations.

  4. The information indicated above has been placed on the tag(s) or post(s).

  5. The lines between the corner post(s) have been marked and boundary post(s) have been erected and marked as required by the Northwest Territories and Nunavut Mining Regulations.

  6. The distances and measurements stated in this application are as accurate as could reasonably be ascertained.

  7. At the time of locating the ground contained within the boundaries of the claim(s) was open for locating under the Northwest Territories and Nunavut Mining Regulations.

  8. The locating is valid and should be recorded.

  9. Compliance was not made with the provisions of __________________________________, of the Northwest Territories and Nunavut Mining Regulations for the following reasons:


Applicant or Agent's Signature   _____________________________________________


Date (YYYY-MM-DD)   _____________________________________________________
 

INTER 50-010E 2012-04-01