NAMES AND ADDRESSES OF AFFECTED LAND OWNERS/OCCUPIERS (See page 3 for information on requirements to complete this page) PART ONE - Landowner notifications required. Section A, Approved Form 24 should be used for these notifications. NT Portion or Section Number Names of Land Owners/Occupiers Address Declaration : I declare the information contained in the table above to be correct, as at / / _____________________ SIGNATURE: NAME: _____________________________ __________________________ SIGNATURE: Witnessed by: NAME: _____________________________ PART TWO Landowner notification declaration – The above landowner notifications were completed on / / Declaration : I declare that the required notifications were completed on the date specified above. SIGNATURE: _____________________ NAME: ___________________________ __________________________ SIGNATURE: Witnessed by: NAME: _____________________________
NAMES AND ADDRESSES OF AFFECTED LAND OWNERS/OCCUPIERS (See page 3 for information on requirements to complete this page) PART ONE - Landowner notifications required. Section A, Approved Form 24 should be used for these notifications. NT Portion or Section Number Names of Land Owners/Occupiers Address Declaration : I declare the information contained in the table above to be correct, as at / / SIGNATURE: __________________________ Witnessed by: NAME: _____________________________ SIGNATURE: _____________________ NAME: _____________________________ PART TWO – Landowner notification declaration The above landowner notifications were completed on / / Declaration : I declare that the required notifications were completed on the date specified above. SIGNATURE: __________________________ Witnessed by: NAME: _____________________________ SIGNATURE: _____________________ NAME: ___________________________
af4-extractive-mineral-exploration-licence-application.docx