Print Form
APPLICATION TO RECORD A MINING
CLAIM IN UNSURVEYED TERRITORY
Pursuant to Subsection 64(1) of The Mines And Minerals Act
PLEASE PRINT
PART 1
I,
(Applicant)
of
(Address)
City
Province
Telephone No.
Fax No.
Postal Code
Hereby declare:
1.
I am of the full age of eighteen years and holder of valid Prospecting Licence No. _____________.
2.
At ______________ o'clock on the _____________ of ___________________________________, ________,
I completed locating, in accordance with the provisions of The Mineral Disposition and Mineral Lease Regulation,
MR 64/92,
Mining Claim, named ____________________________ containing _________ hectares more or less, situated
__________________________________________________________________________________________
(Describe the position of the claim as nearly as possible, giving the numbers or names of any mining
claim it may adjoin.)
3.
The area staked is within the land covered by Claim Map No(s). ___________________________________ .
4.
Corner Post No. 1 has been inscribed with my name and information as set out above in paragraph 2: the post
5.
Corner Posts Nos. 2, 3 and 4 of the claim have been inscribed with the post number, claim name, my name, time
and date as required by the regulation.
6.
I have located witness posts and intersection posts on the boundary of the claim with inscriptions on each post
prescribed by the regulation (as follows):
7.
I have located boundary posts where necessary at not greater than 400 metre intervals with inscriptions on each
post prescribed in the regulation.
8.
number, time, date and claim name.
I have clearly delineated the outer boundaries of the claim by ________________________________________ to
readily identify the claim.
9.
Plan(s) as required by the regulation is/are attached.
10.
This pre-tagged claim is to be recorded under number ____________ and I have affixed the proper tags on the
11.
This untagged claim is to be recorded under number ___________________ and the tags shall be affixed within
one year from the date of recording as set out in Section 19 of the Regulation.
posts as set out in Section 19 of the Regulation.
PLEASE COMPLETE PAGE 2
OFFICIAL USE ONLY
Cheque/Cash/Auth. No.
Date
Amount
Receipt No.
Payer
Amount
REMARKS
MB 13
November 2005
Ce document est disponible en français
12.
I was assisted in this staking by those persons listed below and I accept responsibility for their work in
staking out the claim area:
Name __________________________ Address _____________________________ Licence No. _________
Name __________________________ Address _____________________________ Licence No. _________
To the best of knowledge and belief, the land within the boundaries of this mining claim is not excluded from
staking pursuant to Section 161 of the Act and contains no improvement except as indicated herein
__________________________________________________________________________________________
13.
PART 2
I.
If the claim is to be recorded in a name other than the staker, complete the following:
I direct that the holder of the claim be recorded as:
(Holder)
(Address)
(City)
(Province)
Telephone No. _________________
II.
(Postal Code)
Fax No. _______________________________
If the holder is not a resident of Manitoba, the name and address of a resident agent must be supplied.
Resident Agent
Province MANITOBA
City
Telephone No.
Postal Code
Fax No.
STAKER MUST SIGN
______________________________________
(Date)
_____________________________________
(Staker)
Make cheque payable to the Minister of Finance, Manitoba.
a) A fee of $16.00 accompanies this application for a tagged claim, or
b) A fee of $23.88 (includes .38 GST) accompanies this application for an untagged claim.
NOTE:
1.
2.
It is an offence under The Mines and Minerals Act to make a false statement on this document.
If the holder is a corporation, the corporation must be registered to do business in Manitoba.
Application to be filed at the Office of the Mining Recorder:
WINNIPEG
Unit 360
1395 Ellice Avenue
WINNIPEG, Manitoba
FLIN FLON
Barrow Building
Room 201, 143 Main Street
FLIN FLON, Manitoba
R3G 3P2
Phone: (204) 945-6527
Fax: (204) 948-2578
R8A 1K2
Phone: (204) 687-1630
Fax: (204) 687-1634