Fillable Application For Certificate Of Improvements Form printable pdf download

quartz mining act form 9 section 70

application for certificate of improvements

applicant’s affidavit

Energy, Mines and Resources

_____________________________________________________________________________________ ,

duly authorized agent for ______________________________________________________________ in the

____________________________________________________________________________ mining District

make oath and say that:

1. _____________________________________________________________________________________

is the recorded holder and is in undisputed possession of the ____________________________________

mineral claim, grant number _______________________________________________________situated at

___________________________________________ in the ________________________ mining District

Please provide client i.D. number: __________________________

2. _________________________________________________________________________________ and/or

its predecessors in title have done or caused to be done work on the said claim in developing a mine or made

payment in lieu of work to a value of at least $500.00, full particulars whereof are hereto annexed and marked

“schedule a”.

(note: Particulars must be exclusive of all houses and other like improvements)

3. ___________________________________________ and/or its predecessors in title have found mineral in

place within the said limits of the said claim.

4. the claim was surveyed by _______________________________________________________________

who has made plans for the said claim

(recorded in the canada Lands survey records as Plan _______________).

5. ___________________________________________________________ placed one plan on a conspicuous

part of the land embraced in the plan on the __________________________________________________

6. __________________________________________________posted a copy of the notice hereunto annexed

and marked “schedule B” at the same place as said plan was posted on the ________________________ ,

and another copy in the mining recorder’s office, at _____________ on the ___________ which said notice

and plan have been posted and have remained posted for at least sixty days concurrently with the publication

of the said notice in the ___________________________________ .

7. _______________________________________________________ inserted a copy of the said notice in the

____________________________________________, a canadian paper published in and circulating in the

district in which the claim is situated where it first appeared on the _________________________________

and was published continuously for sixty days.

8. ___________________________________________________________deposited a copy of the plan in the

mining recorder’s office at Whitehorse, on the _________________________________________________

and it remained there for reference for sixty days concurrently with the publication of the said notice in the

newspaper.

sworn before me at __________________________________ this _____ day of ______________ 20 ____ .

____________________________________

__________________________________

notary Public

owner or authorized agent

Access to Information and Protection of Privacy Act

The personal information requested on this form is collected under the authority of and used for the purpose of administering the Quartz Mining Act.

Questions about the collection and use of this information can be directed to the Mining Recorders Office, Mineral Resources, Department of Energy, Mines

and Resources, Yukon Government, Box 2703, Whitehorse, Yukon Territory, Y1A 2C6 (867) 667-3190

Yg(5050qe)f1 rev. 04/2012

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Application For Certificate Of Improvements Form

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