JUNE 16.] THE NEW ZEALAND GAZETTE. 2101

6. That the names of the present owner, lessee, or occupier
   of any of the land referred to in the application are as
   follows :-

7. That I believe myself [or the applicants] to be entitled
   to the grant of the application, and I know of no valid objection thereto.

8. That, so far as I am aware, no public or private rights
   will be prejudicially affected by the grant of the application.

9. [Here set out such other facts as may be necessary.]

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, 1908.

Declared at , this day of , 19 ,
before me— , a Justice of the Peace for the Dominion
of New Zealand [or as the case may be].

FORM 16. [Reg. 55 (1).

In the matter of the Coal-mines Act, 1925; and in the
matter of

[If the land is situated wholly outside a mining district
the application must be made to the Commissioner of Crown
Lands of the land district, and this form must be altered
accordingly.]

To the Warden of the Mining District at
I, [Full name, residence, and occupation], do hereby apply for
the cancellation of the above-mentioned upon the
grounds following, that is to say :-

1. That I am a duly appointed Inspector of Mines under the
   provisions of the Coal-mines Act, 1925.
   Or,

2. That I am adversely affected by the non-compliance of
   the with the conditions of the

[Here set out in consecutively numbered paragraphs
the facts in support of the application, and if the
applicant is not an Inspector of Mines, the manner
in which such non-compliance has affected him.]

Address for service :

Dated at this day of , 19 .
Signature of applicant :
A.B.
[Or, as the case may be,
A.B.
(by his Solicitor or Registered Agent, C.D.)]

Precise time of filing the above application : [e.g., 8th March,
1926, at 2 p.m.]

Time and place appointed for the hearing of the application :
[e.g., Monday, 24th March, 1926, at 10 a.m. at Warden’s Court
at .]

, Mining Registrar.

FORM 17. [Reg. 52 (6).

SUMS AND FEES TO BE LODGED WITH THE RECEIVER IN
CONNECTION WITH THE FILING OF APPLICATIONS, TO ABIDE
THE DISPOSAL OF THE APPLICATION.

Where rent is payable

    One year's rent computed
    on area specified in the ap-
    plication.

    Survey fees as per scale for
    the time being prescribed by
    regulations under the Mining
    Act, 1926, as approximately
    estimated by the Receiver.

    The approximate cost there-
    of as estimated by the Re-
    ceiver, not exceeding £4.

Where survey is necessary ..
Where advertising is required{

Application fee in respect of every application
under the provisions of the Coal-mines Act, 1925, £ s. d.
for a coal-mining right .. .. .. .. 0 5 0

Application fee in respect of every application for
an extension of a coal lease, or to amalgamate
coal leases, or for consent to transfer or assign a
coal lease or a lignite license or a coal-prospecting
license or a tramway license .. .. .. .. 0 5 0

For every other application under the provisions of
the Coal-mines Act, 1925, or these regulations .. 0 2 6

For preparation and issue of any lease or license
or for consent of Minister of Mines to the renewal
or transfer or assignment of any coal-mining
right .. .. .. .. .. .. .. .. 1 1 0

For every other consent of the Minister of Mines
required under the provisions of the Coal-mines
Act, 1925, or these regulations .. .. .. .. 1 1 0

Form 18. [Reg. 234.

Under the Coal-mines Act, 1925.
SHOT-FIRER'S DAILY COLLIERY RECORD

| Day of
Month. | Number or
Shots fired,
exclusive
of
Missfires. | Number
Of
Missfired
Shots. | Total. | Name
of
Explosive. | Remarks.
(Note.-In cases of
missfire state if due
to defective deto-
nator, explosive, or
leads.) | Signature
of
Shot-firer. |
|-----------|--------------------|---------------------|---------------------|-----------------------------|--------------------------|
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |

Note.-A cartridge here recorded shall be a 4 oz. cartridge; a 2 oz. cartridge shall be recorded as half a cartridge.

FORM 19. [Reg.
NOTIFICATION OF SERIOUS AND FATAL ACCIDENTS.

Inspector of Mines,

I have to report that [State here the name of the injured
person], residing at [State here the address of the injured person]
aged years, and engaged as a , was seriously
injured [killed] at a.m. [p.m.] on the day
of , 19 , when working at [State place in the mine
at which the accident occurred] of the [State name of mine] Mine.

The accident was caused by [State here briefly the cause of
the accident], and the injuries sustained were [Here specify
as completely as possible the injuries the injured person received.]

Manager.