Notice to Group

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Form 7

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(We) the undersigned, being the recorded holder(s) or agent(s) for the holder(s) of the following mineral claims: 
 

Mining District

Ο NWT     Ο Nunavut


Claim Sheet No.(s) (NTS)

 


Claim Name
Claim Tag No.
Claim Area (Acres)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


If insufficient space attach a list which shall be known as a schedule and shall form part of this document.
give notice of my(our) intention to group the said claims and do hereby apply under the provisions of Section 37 of the Northwest Territories and Nunavut Mining Regulations to group the said claims for the performance of work. I(We) hereby certify that portions of all the above claims are adjacent.  
Signature(s) of Claim Holder(s) or Agent(s)

 

Date (YYYY-MM-DD)

 

 

Department Use Only

Grouping Certificate
This is to certify that in accordance with the provisions of Section 37 of the Northwest Territories and Nunavut Mining Regulations the claim holder(s) of the above described claims is(are) permitted to group such claims for the performance of work.

 
Mining Recorder's Signature

 

Date (YYYY-MM-DD)

 

Fee

$

Receipt No.

 

Grouping Certificate No.

 


INTER 50-016E 2012-04-01