Prospecting licence duplicate application

Prospecting licence duplicate application
Please note that all information disclosed in this form will be registered in the public Register of real and immovable mining rights.
SECTION 1 : IDENTIFICATION
1.1
BUSINESS ADDRESS OF PROSPECTOR
Name
First name
Address (number, street, R.R. or P.O. box)
Province
Country
Date of birth
App.
Postal code
City
Area code Telephone (home)
-
Area code Fax
Prospecting licence No
Area code Telephone (office) Ext.
-
E-mail address
-
SECTION 2 : COST OF DUPLICATES
The prospecting licence duplicate application must be submitted along with the registration fees which amount to 18,22 $ per duplicate.
Amount to enclose: Number of duplicates
SECTION 3:
x 18,22 $ =
$
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.
X
DATE
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 request 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
2016-12-15