Certificate of Extension

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Form 11

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







 
Mining District
Ο NWT
Ο Nunavut
 

Name(s) of Claim Holder(s)

 


Mailing Address

 

 

 


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

 


Claim Tag No. Claim Name Claim Area (Acres) Existing Excess Credits ($)
(If applicable)		 Deposit Submitted ($)
     
     
     
     
     
     
     
     
     
     
     
     
     
     

If insufficient space, please attach a separate sheet.

Note: All claims must have the same Anniversary Date.

 
 
Reason for Application
  • Illness (Medical Certificate attached)
  • Other (Specify): _____________________________________


Work was to be done during the following period

From (YYYY-MM-DD) _________________   To (YYYY-MM-DD) _________________


Claim Holder or Agent's Signature

 

Date (YYYY-MM-DD)

 


Department Use Only

Certificate

The time in which the required representation work is to be performed is extended to :
______ day of ________________, ___________.


Extension Number

 

Receipt No./Letter of Credit No.

 

Guarantee Deposit

$

Receipt No.

 

Amount of Fees

$

Mining Recorder's Signature

 

Date (YYYY-MM-DD)

 


INTER 50-013E 2012-04-01