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Sec. 18. Effective date - This contract becomes effective as indicated below. <br />If this contract becomes effective on the date BLM signs the contract, BLM will check this box. <br />❑ If this contract becomes effective only after certain conditions are met, BLM will check this box, list the conditions below, and <br />indicate the effective date. <br />Sec. 19. Appeal - You may appeal any decision that BLM makes in regard to this contract under Parts 4 and 1840 of Title 43 of the Code of <br />Federal Regulations. <br />The following parties have executed this contract as of- <br />PURCHASER !� <br />C. <br />J <br />(Individual or Firm Name) <br />;Pc, L a ) <br />(Address) <br />(Pho 66N er - include area code) <br />(Signature) <br />(Signature) <br />f you are a corporation, affix corporate seal here: <br />THE UNITED STATES OF AMERICA <br />By �. <br />-� <br />Ma Y1 <br />(title) <br />i <br />(Date) <br />Title i3 U -S C 1,101, males it a crime for any person knowingly or willfully to make to any department or agency of the United States any false, fictitious or fraudulent <br />statements or ie resentations as to any matter within its jurisdiction subject to a fine of up to $10,000 and imprisonment up to 5 years. <br />NOTICES <br />The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished the following information in connection with information <br />required by this application. <br />AUTHORITY: 30 U.S.C. 601 ct seq.; 43 CFR 3600 <br />PRINCIPAI, PURPOSE: BLM uses this information to identify the parties entering into contracts for disposing of mineral materials. <br />ROU'T'INE USES: BLM will transfer information from the record or the record itself to appropriate Federal, State, local, or foreign agencies, when <br />relevant to criminal, civil, or regulatory investigations or prosecutions. <br />EFFECT OF NOT PROVIDING INFORMATION: If you do not provide this information to BLM, we will not be able to process your application for a <br />contract. <br />The Paperwork Reduction Act of 1995 requires us to inform you that: <br />The BLM is collecting this information to process your application and effect a binding contract. <br />The BLM will use this information to identify and communicate with applicants. <br />You must respond to this request to get a benefit. <br />The BLM would like you to know that you are not required to respond to. this or any other Federal agency- sponsored information collection which does <br />not have a currently valid OMB control number. <br />BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average about 30 minutes per response, including the <br />time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden <br />estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004- 0103), Bureau Information <br />Collection Clearance Officer (WO -630) 1849 C Street N W Mail Stop 401 LS Washington, D.C. 20240. <br />(Form 3600 -9, page 3) <br />