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Application For A Lease To Prospect Form

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PLACER MINING ACT FORM 6 SECTION 92

APPLICATION FOR A LEASE TO PROSPECT

Office Date Stamp

Submit to District Mining Recorder

A sketch must accompany this application

___________________________________________________ Mining District

I , ______________________________________________________________ ,

Name

occupation ________________________________________________________ ,

of ______________________________________________________________ ,

postal address

Phone ___________________________________________________________ ,

hereby apply under the provisions of the Placer Mining Act for a lease to prospect in the manner defined in the

said Act on that

portion of _________________________________________ creek (or river) which may be described as follows

and I MAKE OATH AND SAY THAT:

1. To the best of my knowledge and belief the land is such as may be located for prospecting purposes under the

said Act;

2. That I did on the ___________________ day of ____________________________________ ,20 ______

mark out on the ground in accordance in every particular with the said Act the location for which I make this

application;

3. The length of the location, as nearly as I could measure it is, __________________________________ feet,

and that the description above given in detail sets forth to the best of my knowledge and ability its position;

4. I staked out the location by planting two legal posts, numbered 1 and 2, respectively, and that No.1 is the

downstream post of the location and the line between posts is well cut out: (Section 24(3) PMA)

5. That no placer mining claims are now recorded on the tract applied for, and that no placer mining operations

are now being conducted thereon;

6. I make this application in good faith to acquire a prospecting lease for the sole purpose of prospecting and

mining to be prosecuted by myself, or by myself and associates, or by my assigns.

Sworn before me at ___________________________________ this ______ day of ______________ 20 ____ .

Notary Public

Applicant

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 Placer

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 or toll

free at 1-800-661-0408 ext. 3190.

YG(5052EQ)F1 Rev.05/2016

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Application For A Lease To Prospect Form

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