Government of Ontario: Ministry of Northern Development and Mines

Application for Lease
Mining Act

Transaction No.

Personal information collected on this form is obtained under the authority of section 81 of the Mining Act. Under section 7 of the Act, this information is used to maintain a public record. This information will also be used for invoicing annual rental and serving notices. Questions about this collection should be directed to the Senior Manager, Mining Lands, Ministry of Northern Development and Mines, 3^rd Floor, 933 Ramsey Lake Road, Sudbury ON P3E 6B5. Telephone 1 888 415-9845.

Name of Applicant
Client No.

Street No. Street Name
Unit/Suite/Apt City/Town or Village
Province/State Country
Postal Code/Zip Code

Telephone No. ( )

Fax No. ( )

The Recorded Holder of an Interest in Mining Claim Number(s)

Apply for a lease for Mining and Surface Rights
Mining Rights Only

The lease document(s) will be issued as Individual Leases
Single Lease

Accompanying this application:

Approved plan of survey, where required under the Mining Act
Agreement or order of Commissioner that Surface Rights compensation, if any, has been paid, secured or settled
$ in payment of the rental for the first year
Application fee.

Name of Recorded Holder(s)	Address	Interest Held
Name of Recorded Holder(s)	Address	Interest Held
Name of Recorded Holder(s)	Address	Interest Held
Name of Recorded Holder(s)	Address	Interest Held
Name of Recorded Holder(s)	Address	Interest Held
Name of Recorded Holder(s)	Address	Interest Held

Signature of Applicant

Date of application (yyyy/mm/dd)

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Government of Ontario: Ministry of Northern Development and Mines

Application for Lease Mining Act

Application for Lease
Mining Act