Print, fill in the infomation requested below and mail to:
| Your info: | ||
| Your Name: | _____________________________________________ | |
| Address: | _____________________________________________ | |
| _____________________________________________ | ||
| _____________________________________________ | ||
| Phone: | _____________________________________________ | |
| _____________________________________________ | ||
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| Nominee Info | ||
| Name: | _____________________________________________ | |
| Address of physical location of nominee or his/her location of mining interest: |
____________________________________________________________________________
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| Vital statistics for nominee, including date of birth and death, names of parents and nearest relatives: | ____________________________________________________________________________
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ |
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Contributions to or achievements in mining or mine related activity: |
____________________________________________________________________________
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ |
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