Power Of Attorney Form
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1POWER OF ATTORNEY
Office Date Stamp
I, _______________________________________________________________________of
Name of Appointer
________________________________________________________________________ in
Postal Address, City
_________________________________________________________________________
Territory/Province and Postal Code
do herby APPOINT:
_______________________________________________________________________________________________ of
_________________________________________________________________________________________________
Territory/Province and Postal Code
to be my Attorney to:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
This power of Attorney for the
Mining District to expire on: _________________
HEREBY GIVING AND GRANTING unto my said Attorney full power and authority to do and perform any and all
or every act and thing whatsoever requisite and necessary to be done for this purpose as I might or could do if personally
present and acting in my own behalf.
HEREBY AGREEING TO RATIFY AND CONFIRM all that my said Attorney may lawfully do or cause to be done by
virtue of this power of attorney.
IN WITNESS WHEREOF _____________________________________________________________________
Name of Appointer
have hereunto set my hand and seal at _________________________________________________________________
City and Territory/Province
this _____________________________________ day of _________________________________________ , 20 _______ .
SIGNED, SEALED and DELIVERED by the appointer in the presence of:
________________________________________
______________________________________
Witness to Signature of Appointer
Appointer
AFFIDAVIT OF WITNESS
I, _________________________________________________, _______________________________________________,
Name
Occupation
of _________________________________________________________________________________________________
Complete postal address
make oath and say THAT:
1. I was personally present and did see ______________________________________________________, the person
named as the Appointer in the attached Power of Attorney Form duly sign that instrument at the time and place indicated
in the instrument.
2. I personally know the person whose signature I witnessed.
OR
The Identity of the person whose signature I witnessed has been proven to me to my satisfaction.
3. To the best of my knowledge and belief, the person whose signature I witnessed is of the legal age to execute the
instrument.
Sworn before me at _________________________________________ this ______ day of ________________ 20 _____ .
_______________________________________
_________________________________________
Notary Public
Witness
Access to Information and Protection of Privacy Act
This information is being collected under the authority of the Quartz Mining Act and Placer Mining Act. For further
information contact the Department of Energy, Mines and Resources, Mining Recorders Office at 867-667-3190 or toll free
at 1-800-661-0408 extension 3190.
YG(5045Q)F1 Rev. 05/2016
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