JUNE 28.] THE NEW ZEALAND GAZETTE. 1203

(1.) My practical experience consists of actual employment as specified in the Schedule hereto; and in proof thereof I herewith supply evidence in writing from my previous employers, as specified in that Schedule.

(2.) [If the applicant is a candidate for examination for a mine-manager's certificate, and already holds a certificate of the second class, add] I am the holder of a second-class certificate, No. , and desire to be examined for a certificate of the first class.

Dated at , this day of , 1 .

SCHEDULE.

Particulars and Proof of Employment.

[Signature of applicant.]

Form 73 (Reg. 16).

Under “The Mining Act, 1898.”

MINE-MANAGER’S CERTIFICATE OF FIRST [or SECOND] CLASS BY EXAMINATION.

: This is to certify that [Full name, occupation, and residence], has by examination duly satisfied the Board of Examiners that he is entitled to a mine-manager’s certificate of the first [or second] class, and this first- [or second-] class certificate is hereby issued to him accordingly.

: Issued at Wellington, this day of , 1 , by the Board of Examiners.

Signature of holder:

C.D.,
Secretary.

A.B.,
Chairman.

Form 74 (Reg. 16).

Under “The Mining Act, 1898.”

MINE-MANAGER’S CERTIFICATE OF FIRST [or SECOND] CLASS WITHOUT EXAMINATION.

: This is to certify that [Full name, occupation, and residence], having duly satisfied the Board of Examiners that he is the holder of a corresponding certificate of equal status, granted after examination by [Name of authority] (being a duly constituted and recognised authority outside New Zealand), this first- [or second-] class certificate as mine-manager is hereby granted to him accordingly without examination.

: Issued at Wellington, this day of , 1 , by the Board of Examiners.

Signature of holder:

C.D.,
Secretary.

A.B.,
Chairman.

Form 75 (Reg. 16).

Under “The Mining Act, 1898.”

BATTERY SUPERINTENDENT’S CERTIFICATE BY [or WITHOUT] EXAMINATION.

[As in Forms Nos. 73 or 74, or with all necessary modifications.]

Form 76 (Reg. 18).

Under “The Mining Act, 1898.”

APPLICATION FOR DUPLICATE OF LOST OR DESTROYED DOCUMENT.

To the Warden of the Mining District, at .

I, THE undersigned [Full name of applicant], of [Residence and occupation], being the lawful holder of the miner’s right [license or other document] specified in the Schedule hereto, hereby apply for the issue of a duplicate thereof on the ground that the original has been lost or destroyed; and in support of this application I do hereby solemnly and sincerely declare as follows:—

1. I am the lawful holder of the document above referred to, and it was lost [or destroyed] under the following circumstances: [Set out as far as known the date on which and the manner in which the loss or destruction occurred].

2. I have made diligent search for the said document, but have been unable to find it.

3. I have not, nor with my knowledge or consent has any other person, deposited the said document with any person for purposes of security or otherwise, and I verily believe it to be lost [or destroyed].

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of “The Justices of the Peace Act, 1882.”

THE SCHEDULE ABOVE REFERRED TO.

[Set out the name of the document, the Act under which it was issued, the registration or other number, and such other particulars as will suffice to identify it.]

Declared by the said , at , this day of , 1 , before me— , J.P. [Solicitor, or other person authorised to take statutory declarations].

Form 77 (Reg. 19).

Under Section 109 of “The Mining Act, 1898.”

CLAIM SETTING FORTH FULL PARTICULARS OF THE COMPENSATION THAT WILL BE REQUIRED IN THE EVENT OF WATERCOURSE BEING CONSTITUTED AND SET APART FOR DISCHARGE OF TAILINGS.

To the Minister of Mines, at Wellington.

WHEREAS by notice published in the Gazette on the day of , 1 , it is stated that application has been made to His Excellency the Governor to constitute and set aside by Proclamation the watercourse described in Table A hereunder to be a watercourse into which may be discharged tailings, débris, and waste water produced by or resulting from mining operations: And whereas by the operation of such Proclamation, if made, the lands described in Table B hereunder, in which I have an interest, as described in Table C hereunder, will be damaged or injuriously affected by reason that [Here state items of claim, with a reference number to each, and give in each case full particulars of the nature and extent of each such item]:

Now, therefore, this is to give notice that in the event of such Proclamation being made I shall claim £ as compensation for all loss and damage arising from the operation thereof, which sum is made up as follows:—

[Here state reference number and short heading of each item of claim previously detailed, and the amount claimed in respect of each such item separately.]

Total claim .. ..

Given under my hand, at , this day of , 1 .

Claimant:
[Christian name and surname in full].

Address:
[Address in full].

TABLE A.

[Here describe the watercourse, as in the Gazette notice.]

TABLE B.

[Here describe the area and situation of the lands affected, giving name of survey district and number and block of section, or other means of identification.]

TABLE C.

[Here state in full the nature of the interest, as owner in fee-simple, mortgagee, lessee, or occupier; and if the lands are leased or encumbered, or subject to any easement, give particulars thereof.]

SECOND SCHEDULE.

SUBSTITUTED FORMS.

Form 78 (Reg. 28).

APPLICATION FOR PROSPECTING WARRANT OR LICENSE IN RESPECT OF OTHER THAN NATIVE LAND.

To the Warden of the Mining District, at .

PURSUANT to “The Mining Act, 1898,” the undersigned [Full name, occupation, and residence], hereby applies for a prospecting warrant [or ordinary prospecting license or tunnel prospecting license] in respect of the following land (being other than Native land):—

[Here specify and identify the land with reasonable particularity by reference to its area, situation, and ownership; in the case of a tunnel prospecting license specify also starting and terminal points, estimated length, and proposed course of the tunnel.]