Form 3510-1 - Prospecting Application And Permit

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FORM APPROVED

UNITED STATES DEPARTMENT OF

Form 3510-1

OMB NO. 1004-0121

(Aug 2016)

Expires: August 31, 2019

THE INTERIOR BUREAU OF LAND

MANAGEMENT

1. Serial Number (See Specific Instructions - Item 1)

PROSPECTING APPLICATION AND PERMIT

2. What mineral(s) are you applying for?

3a. Applicant’s name

5. Legal description of land included in permit

APPLICANT DOES NOT FILL IN THIS SPACE

3b. Applicant’s address

4. Give legal description of land requested (See General Instructions, Item 4)

Total acres

Rental submitted $

Total acres

Rental retained $

6. Are the lands administered by a government agency?

Yes

(If “Yes,” give name of agency)

Yes

7. Are you the sole party in interest?

(See Specific Instructions - Item 7)

8a. Are you a citizen of the United States?

8b. Are you over the age of majority?

Yes

9a. Is application made for a corporation or other legal entity?

Yes

(If “Yes,” see Specific Instructions - Item 9a)

9b. Has a statement of qualification been filed?

Yes

(If “Yes,” give file number, if “No,” see regulation 43 CFR 3502)

10. A processing fee will be determined on a case-by-

11. Be sure to enclose the first year’s advance rental computed at the rate

case basis. (See Specific Instructions - Item 10)

of 50¢ per acre or fraction thereof (See Specific Instructions - Item 11)

I CERTIFY That my interests, direct or indirect, in leases, permits, and applications therefor, do not exceed the maximum permitted by law or

regulation, and that the statements made herein are true, complete, and correct to the best of my knowledge and belief and are made in good faith.

(Signature of Applicant)

(Date)

(Attorney-in-fact)

Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United States any false,

fictitious or fraudulent statements or representations as to any matter within its jurisdiction.

DO NOT WRITE BELOW THIS LINE

PROSPECTING PERMIT

(Name of Mineral(s)

A permit for the lands in Item 5, above, is hereby issued under the

below) and is subject to all regulations found in 43 CFR 3500 and to the

terms and conditions set forth on the reverse hereof.

Mineral Leasing Act, 30 U.S.C. 181 et seq.,

Acquired Lands Leasing

Act, 30 U.S.C. 351 et seq.,

Section 402 of Reorganization Plan No. 3

This permit, to the extent applicable, is subject to standard and/or special