Applicant (e.g., landowner, licencee, permittee, etc.) (Cannot be a subcontractor)

Indicate and complete the appropriate additional part(s)

Personal Information on this form is collected under the authority of Section 13 of the Public Lands Act, R.S.O. 1990 and Ontario Regulation 453/96 as amended and Ontario Regulation 975 as amended, and the information will be used for the purposes of the Act and Regulations. Questions about this information should be directed to the local MNRF office. MNRF office addresses and phone numbers are listed on the reverse of this form.

I/We hereby agree to rely solely upon the terms and conditions of the written work permit issued pursuant to this application. Any changes,
amendments to the written work permit must be approved in writing by MNRF.

I certify the information given in this application is true

Note: The issuance of this permit does not relieve the applicant from the responsibility of acquiring any other agency, board, government, or other approvals as may be required.

If an applicant requires a copy of this application, the applicant should retain copy prior to submitting.

Contact information and locations for regional and district MNRF offices in Ontario

Northeast Region
Regional Office
South Porcupine Ontario Government Complex,
5520 Hwy 101 E, PO Bag 3020, South Porcupine, ON P0N 1H0
1-800-667-1940

Chapleau District
190 Cherry St, PO Box 460, Chapleau, ON P0M 1K0
705-864-1710

Cochrane District
4-2 Hwy 11 S, Cochrane, ON P0L 1C0
705-272-4365

Hearst District
Government Complex, 613 Front St, PO Box 670, Hearst, ON P0L 1N0
705-362-4346

Kirkland Lake District
2nd Flr, 145 Government Rd W, Kirkland Lake, ON P2N 2E8
705-568-3222

North Bay District
3301 Trout Lake Rd, North Bay, ON P1A 4L7
705-475-5550

Sault Ste Marie District
64 Church St, Sault Ste Marie, ON P6A 3H3
705-949-1231

Sudbury District
Suite 5, 3767 Hwy 69 S, Sudbury, ON P3G 1E7
705-564-7823

Timmins District
Ontario Government Complex, 5520 Hwy 101 E, PO Bag 3090, South Porcupine, ON P0N 1H0
705-235-1300

Wawa District
48 Mission Rd, Wawa, ON P0S 1K0
705-856-2396

Northwest Region
Regional Office – Thunder Bay
435 South James St, Thunder Bay, ON P7E 6S7
1-800-667-1940

Dryden District
2nd Flr, 479 Government Rd, PO Box 730, Dryden, ON P8N 2Z4
807-223-3341

Fort Frances District
922 Scott St, Fort Frances, ON P9A 1J4
807-274-5337

Kenora District
808 Robertson St, PO Box 5080, Kenora, ON P9N 3X9
807-468-2501

Nipigon District
5 Wadsworth Dr, PO Box 970, Nipigon, ON P0T 2J0
807-887-5000

Red Lake District
227 Howey St, PO Box 5003, Red Lake, ON P0V 2M0
807-727-2253

Sioux Lookout District
49 Prince St, PO Box 309, Sioux Lookout, ON P8T 1A6
807-737-1140

Thunder Bay District
Ontario Government Bldg Suite B001, 435 James St S, Thunder Bay, ON P7E 6S7
807-475-1471

Southern Region
Regional Office
4th Flr S, 300 Water St, Peterborough, ON K9J 3C7
1-800-667-1940

Aurora District
50 Bloomington Rd, Aurora, ON L4G 0L8
905-713-7400

Aylmer District
615 John St N, Aylmer, ON N5H 2S8
519-773-9241

Bancroft District
106 Monck St, PO Box 500, Bancroft, ON K0L 1C0
613-332-3940

Guelph District
Ontario Government Bldg, 1 Stone Rd W, Guelph, ON N1G 4Y2
519-826-4955

Kemptville District
Unit 1, 10 Campus Dr, Kemptville, ON K0G 1J0
613-258-8204

Midhurst District
2284 Nursery Rd, Midhurst, ON L9X 1N8
705-725-7500

Parry Sound District
7 Bay St, Parry Sound, ON P2A 1S4
705-746-4201

Pembroke District
31 Riverside Dr, Pembroke, ON K8A 8R6
613-732-3661

Peterborough District
1st Flr S, 300 Water St, Peterborough, ON K9J 3C7
705-755-2001