Notice of Surrender

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Form 12 - Submit in Duplicate

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 depositing a notice of surrender. 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.

 
To the Mining Recorder for the Mining District of
  • NWT  
  • Nunavut
 

Name(s)

 

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

 

Address(es)

 

 

 

I(We) give notice that I(we) intend to surrender the following Mineral Claim(s):


Claim Tag No. 
Claim Name
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Situate in (Claim Sheet No.(s))

 

Dated at     ________________ this ___________ day of _______, _________

Signature(s) of Recorded Claim Holder(s)

 


 
  Department Use Only
 

I HEREBY CERTIFY that the above Notice of Surrender is approved.

Supervising Mining Recorder's Signature

 


 
  For Use of the Mining Recorder Only

I HEREBY DECLARE that this notice is accepted and recorded in accordance with Section 51 of the Northwest Territories and Nunavut Mining Regulations and you may relocate the area of the above noted mineral claim(s) or any part thereof within a period of seven days from the date shown hereunder.

Mining Recorder's Signature

 

Date (YYYY-MM-DD)

 

Fee

$

Receipt No.

 

INTER 50-050E 2012-04-01