Personal information collected on this form is obtained under the authority of the Mining Act. This information will be used for invoicing annual rental and servicing notices. Questions about this collection should be directed to the Senior Manager, Mining Lands, Ministry of Northern Development and Mines, 3rd Floor, 933 Ramsey Lake Road, Sudbury, Ontario, P3E 6B5.
Name of Applicant in Full (Enter Corporate Name if Application Made on Behalf of a Corporation)
Street Number Street Name Unit/Suite/Apt City, Town or Village Province/State Country Postal Code/Zip Code
being the holder of Licence of Occupation No. or being the lessee or owner of mining rights described as follows: Lease No., Parcel No., Township, Lot, Concession, or Area
The applicant applies for the issue of a Surface Rights Lease under the provisions of the Mining Act, for the land described as follows: Township, Lot, Concession or Area
M or G Plan Number
Statement of the purpose for which the surface rights are to be used Description of the area applied for Survey plan or sketch First year’s rent of $ Application fee Proof of ownership (Deed or Parcel Register or Registrar’s Abstract)
Signature of Applicant
If Signing Officer for Corporation, State Office Held
Date
"Mining Lands Website: http://www.mndm.gov.on.ca/mndm/mines/lands/default_e.asp"
0229E (2022/11)
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