Prospecting licence application

Prospecting licence application
Please note that all the information disclosed on this form will be recorded in the public Register of real and
immoveable mining rights.
SECTION 1 : IDENTIFICATION
1.1
IDENTIFICATION OF APPLICANT COMPANY (If different from prospector’s identification)
Name of company
Company registration no
Name
First name
Address (number, street, R.R. or P.O. box)
App.
Province
Country
Postal code
Area code Fax
Client no
Date of birth
Client no
City
Area code Telephone (home)
-
Area code Telephone (office) Ext
-
E-mail address
-
1.2
MAILING ADDRESS OF PROSPECTOR
Name
First name
Address (number, street, R.R. or P.O. box)
App.
Province
Country
Postal code
Area code Fax
Date of birth
Client no
City
Area code Telephone (home)
-
Area code Telephone (office) Ext
-
E-mail address
If insufficient space, print another page
SECTION 2 : COST OF LICENCE
The prospecting licence application must be submitted along with the fees which amount to 36,99 $ per licence.
Amount to enclose : Number of licence
x 36,99 $ =
$
SECTION 3:
PAYMENT
The payment must be joined to this form.
By check: Due to the Ministre des finances
It is forbidden to write credit card information on this form.
SECTION 4:
STATEMENT
Write your name and first name in block letters
Name of signatory
First name of signatory
I hereby certify that all information disclosed in this form is accurate and complete.
DATE
X
SIGNATURE
Please send this form by mail only to :
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
5700, 4e Avenue Ouest, local C-320
Québec (Québec) G1H 6R1
Note: You may file your application of prospecting license online on the GESTIM website (gestim.mines.gouv.qc.ca). Credit card payments
are accepted online.
Ministère de l’Énergie et des Ressources naturelles
Service de la gestion des droits miniers
2015-12-15