Application For Grant For Placer Mining Form
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1PLACER MINING ACT FORM 1 SECTION 27
APPLICATION FOR GRANT FOR PLACER MINING
Energy, Mines and Resources
Version française
Office Date STamp
____________________________________________________ Mining District
I _______________________________________________________________ ,
Full Name
Occupation ___________________________ , Phone __________________ of
_______________________________________________________________ ,
Postal Address
hereby apply, under the Placer Mining Act for a grant of a claim for Placer Mining
as defined in the said Act in
_______________________________________________________________________________________
Here describe locality
_______________________________________________________________________________________
INSCRIPTION ON NO. 1 POST: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
INSCRIPTION ON NO. 2 POST: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
And I make Oath and Say that:
1. To the best of my knowledge and belief, the land is such as can be located under Section 17 of the said Act.
2. I did on the ________________________ day of _____________________________________ 20 _______
mark out on the ground, in accordance on every particular with the provisions of the said Act, the claim for
which I make this application and in so doing I did not encroach on any other claim or mining location
previously laid out by any other person.
3. The length of the said claim, as nearly as I could measure is __________________________________ feet
and that the description sets forth to the best of my knowledge and ability, its position.
4. I staked out the claim by planting two legal posts numbered 1 and 2 respectively.
5. I make this application in good faith to acquire the claim for the sole purpose of mining to be prosecuted by
myself or by myself and associates or by my assigns.
Sworn before me at ___________________________________ this ______ day of _______________ 20 ____
_____________________________________
_____________________________________
Notary
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.
YG(5038Q) F2 04/2003
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