Application For A Certificate Of Work Form

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quartz mining act form 4 section 56

application for a certificate of work

Energy, Mines and Resources

Office Date Stamp

_______________________________________________________________ ,

_______________________________________________________________

of _______________________________________________________________

Phone ____________________________________________________________

client i.D. number: __________________________________________________

make oath and say that:

1. i am the owner, or agent of the owner, of the mineral claim(s) to which reference is made herein.

2. i have done, or caused to be done, work, on the following mineral claim(s): (Here list claims on which work

was actually done by number and name)

_____________________________________________________________________________________

situated at __________________________________ claim sheet no. ____________________________

in the ___________________________ mining District, to the value of at least ________________ dollars,

since the _________________________ day of ____________________________________ 20 _______ ,

to represent the following mineral claims under the authority of Grouping Certificate No. _______________ .

(Here list claims to be renewed in numerical order, by grant number and claim name, showing renewal period

requested).

_____________________________________________________________________________________

3. the following is a detailed statement of such work: (set out full particulars of the work done indicating dates

work commenced and ended in the twelve months in which such work is required to be done as shown by

section 56).

_____________________________________________________________________________________

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(5049q)f2 rev. 04/2012

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