Canada Oil and Gas Land Regulations (C.R.C., c. 1518)

I, , holder of Oil and Gas Permit No. issued pursuant to

(insert the reference to the Regulations under which the permit was issued)

and in effect on the 23rd day of September, 1957, hereby request from and after the day of filing of this Request with the Chief of the Resources Division, the said permit shall be subject to the Canada Oil and Gas Land Regulations.

Dated at this day of , 19