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I 
of (Address)(Occupation of applicant) hereby apply for a licence on my behalf or on behalf of to explore for coal on the following lands described as (indicate in ☐ by (x) which quarter(s) applied for)
NW Quarter ☐
SW Quarter ☐ of mineral claim staking sheet(s) No
SE Quarter ☐
NE Quarter ☐
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Pursuant to application dated 19 made under section 35 of the Territorial Coal Regulations(Name of Licensee) is hereby authorized to explore for coal on the Quarter(s) of the area of land shown on mineral claim staking sheet No. containing approximately acres of land, for a period of three years commencing on the day of 19 subject to the Territorial Coal Regulations.
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