Document:

Goldrich Mining Company

Exhibit 10.4

Form of Class F Warrant Certificate

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THE SECURITIES REPRESENTED HEREBY HAVE NOT BEEN AND WILL NOT BE REGISTERED UNDER THE UNITED STATES SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”).  THESE SECURITIES MAY BE OFFERED, SOLD, PLEDGED OR OTHERWISE TRANSFERRED ONLY (A) TO THE COMPANY, (B) IF THE SECURITIES HAVE BEEN REGISTERED IN COMPLIANCE WITH THE REGISTRATION REQUIREMENTS UNDER THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS (C) IN COMPLIANCE WITH THE EXEMPTION FROM THE REGISTRATION REQUIREMENTS UNDER THE SECURITIES ACT IN ACCORDANCE WITH RULE 144 THEREUNDER, IF APPLICABLE, AND IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS, OR (D) IN A TRANSACTION THAT DOES NOT REQUIRE REGISTRATION UNDER THE SECURITIES ACT OR ANY APPLICABLE STATE LAWS AND REGULATIONS GOVERNING THE OFFER AND SALE OF SECURITIES, AND THE HOLDER HAS, PRIOR TO SUCH SALE, FURNISHED TO THE COMPANY AN OPINION OF COUNSEL OF RECOGNIZED STANDING, OR OTHER EVIDENCE OF EXEMPTION, REASONABLY SATISFACTORY TO THE COMPANY.  HEDGING TRANSACTIONS INVOLVING THE SECURITIES REPRESENTED HEREBY MAY NOT BE CONDUCTED UNLESS IN COMPLIANCE WITH U.S. SECURITIES LAWS.

THIS WARRANT AND THE SECURITIES DELIVERABLE UPON EXERCISE HEREOF HAVE NOT BEEN REGISTERED UNDER THE UNITED STATES SECURITIES ACT OF 1933, AS AMENDED (THE “U.S. SECURITIES ACT”), OR THE SECURITIES LAWS OF ANY STATE OF THE UNITED STATES.  THIS WARRANT MAY NOT BE EXERCISED BY OR ON BEHALF OF A “U.S. PERSON” OR A PERSON IN THE UNITED STATES UNLESS THE WARRANT AND THE UNDERLYING SECURITIES HAVE BEEN REGISTERED UNDER THE U.S. SECURITIES ACT AND THE APPLICABLE SECURITIES LEGISLATION OF ANY SUCH STATE OR AN EXEMPTION FROM SUCH REGISTRATION REQUIREMENTS IS AVAILABLE.  “UNITED STATES” AND “U.S. PERSON” ARE AS DEFINED BY REGULATION S UNDER THE U.S. SECURITIES ACT.

GOLDRICH MINING COMPANY

CLASS F WARRANTS 

TO PURCHASE SHARES

OF COMMON STOCK OF

GOLDRICH MINING COMPANY

CERTIFICATE NO.:  ̈

Class F Warrant to Purchase

 ̈ Shares of Common Stock

[DATE]

(“Issue Date”)

FOR VALUE RECEIVED, GOLDRICH MINING COMPANY, an Alaska corporation (the "Company"), hereby certifies that __________________________________, its successor or permitted assigns (the "Holder"), is entitled, subject to the provisions of this Class F Warrant, to purchase from the Company, at the times specified herein,  ̈ fully paid and non-assessable shares of common stock of the Company, par value $0.10 per share (the "Common Shares"), at a purchase price per share equal to the Exercise Price (as hereinafter defined).

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1.

Definitions.  (a)  The following terms, as used herein, have the following meanings:

"Affiliate" shall have the meaning given to such term in Rule 12b-2 promulgated under the Securities and Exchange Act of 1934, as amended.

"Business Day" means any day except a Saturday, Sunday or other day on which commercial banks in the City of Spokane, Washington are authorized by law to close.

"Common Stock" means the Common Stock, par value $0.10 per share, of the Company.

"Duly Endorsed" means duly endorsed in blank by the Person or Persons in whose name a stock certificate is registered or accompanied by a duly executed stock assignment separate from the certificate with the signature(s) thereon guaranteed by a commercial bank or trust company or a member of a national securities exchange or of the Financial Industry Regulatory Authority.

“Exercise Date” means the date a Warrant Exercise Notice is delivered to the Company in the manner provided in Section 9 below.

"Exercise Price" means $0.55.

"Expiration Date" means 5:00 p.m. (Spokane, Washington) on [________, 2010]; provided that if such date shall in the City of Spokane, Washington be a holiday or a day on which banks are authorized to close, then 5:00 p.m. on the next following day which in the City of Spokane, Washington is not a holiday or a day on which banks are authorized to close.

"Initial Warrant Exercise Date" means the date hereof.

"Person" means an individual, partnership, corporation, trust, joint stock company, association, joint venture, or any other entity or organization, including a government or political subdivision or an agency or instrumentality thereof.

“Principal Market” means the OTCBB or

 the primary securities exchanges or market on which such security may at the time be listed or quoted for trading.

“Trading Day” means any day on which trading occurs on the OTCBB (or such other exchange or market as the Common Shares may trade on in the United States).

"Warrant Shares" means the Common Shares deliverable upon exercise of this Class F Warrant, as adjusted from time to time.

2.

Exercise of Class F Warrant.

(a)

Subject to Section 2(f), the Holder is entitled to exercise this Class F Warrant in whole or in part at any time on or after the Initial Warrant Exercise Date until the Expiration Date.  To exercise this Class F Warrant, the Holder shall execute and deliver to the Company a Warrant Exercise Notice substantially in the form annexed hereto.  No earlier than five (5) days after delivery of the Warrant Exercise Notice, the Holder shall deliver to the Company this Class F Warrant Certificate, including the Warrant Exercise Subscription Form forming a part hereof duly executed by the Holder, together with payment of the applicable Exercise Price.  Upon such delivery and payment, the Holder shall be deemed to be the holder of record of the Warrant Shares subject to such exercise, notwithstanding that the stock transfer books of the Company shall then be closed or that certificates representing such Warrant Shares shall not then be actually delivered to the Holder.  No fractional shares will be issued.

(b)

The Exercise Price may be paid to the Company in cash or by certified or official bank check or bank cashier's check payable to the order of the Company, or by wire transfer or by any combination of cash, check or wire transfer.

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(c)

If the Holder exercises this Class F Warrant in part, this Class F Warrant Certificate shall be surrendered by the Holder to the Company and a new Class F Warrant Certificate of the same tenor and for the unexercised number of Warrant Shares shall be executed by the Company.  The Company shall register the new Class F Warrant Certificate in the name of the Holder or in such name or names of its transferee pursuant to paragraph 6 hereof as may be directed in writing by the Holder and deliver the new Class F Warrant Certificate to the Person or Persons entitled to receive the same.

(d)

Upon surrender of this Class F Warrant Certificate in conformity with the foregoing provisions, the Company shall transfer to the Holder of this Class F Warrant Certificate appropriate evidence of ownership of the Common Shares or other securities or property to which the Holder is entitled, registered or otherwise placed in, or payable to the order of, the name or names of the Holder or such transferee as may be directed in writing by the Holder, and shall deliver such evidence of ownership and any other securities or property to the Person or Persons entitled to receive the same.  

(e)

In no event may the Holder exercise these Class F Warrants in whole or in part unless the Holder is an “accredited investor” as defined in Regulation D under the Securities Act of 1933, as amended (the “U.S. Securities Act”), or the Holder is a non-U.S. person (as defined in Regulation S of the U.S. Securities Act) exercising these Class F Warrants in an “off shore transaction” in accordance with the requirements of Regulation S of the U.S. Securities Act. 

(f)

In the event that the Common Shares trade on the Principal Market in the United States at a weighted volume average price of greater than $0.80 per share for a period of 20 consecutive Trading Days at any time following the issuance of the Class F Warrants, the Company may, in its sole discretion, accelerate the Expiration Date of the Warrants by giving written notice to the holders thereof within 10 Business Days of the occurrence thereof and in such case the Warrants will expire on the 20th Business Day after the date on which such notice is given by the Company.

3.

Exercise Restrictions.  Notwithstanding any other provision hereof, no Holder shall exercise these Class F Warrants, if as a result of such conversion the holder would then become a “ten percent beneficial owner” (as defined in Rule 16a-2 under the Securities Exchange Act of 1934, as amended) of Common Shares.  For greater certainty, the Class F Warrants shall not be exercisable by the Holder or redeemed by the Company, if, after giving effect to such exercise, the holder of such securities, together with its affiliates, would in aggregate beneficially own, or exercise control or direction over that number of voting securities of the Company which is 9.99% or greater of the total issued and outstanding voting securities of the Company, immediately after giving effect to such exercise; provided, however, that upon a holder of these Class F Warrants providing the Company with a Waiver Notice that such holder would like to waive the provisions of this paragraph 3 with regard to any or all Common Shares issuable upon exercise of these Class F Warrants, this paragraph 3 shall be of no force or effect with regard to those Common Shares referenced in the Waiver Notice; provided, further, that this provision shall be of no further force or effect during the sixty-one (61) days immediately preceding the expiration of the term of these Class F Warrants.

4.

Restrictive Legend.  Certificates representing Common Shares issued pursuant to this Class F Warrant shall bear a legend substantially in the form of the legend set forth on the first page of this Class F Warrant Certificate to the extent that and for so long as such legend is required pursuant to applicable law.

5.

Covenants of the Company.

(a)

The Company hereby agrees that at all times there shall be reserved for issuance and delivery upon exercise of this Class F Warrant such number of its authorized but unissued Common Shares or other securities of the Company from time to time issuable upon exercise of this Class F Warrant as will be sufficient to permit the exercise in full of this Class F Warrant.  All such shares shall be duly authorized and, when issued upon such exercise, shall be validly issued, fully paid and non-assessable, free and clear of all liens, security interests, charges and other encumbrances or restrictions on sale and free and clear of all preemptive rights.

(b)

The Company shall not by any action, including, without limitation, amending its certificate of 

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incorporation or through any reorganization, transfer of assets, consolidation, merger, dissolution, issue or sale of securities or any other voluntary action, avoid or seek to avoid the observance or performance of any of the terms of this Class F Warrant, but will at all times in good faith assist in the carrying out of all such terms and in the taking of all such actions as may be necessary or appropriate to protect the rights of Holder against impairment.  Without limiting the generality of the foregoing, the Company will (i) not increase the par value of any Common Shares receivable upon the exercise of this Class F Warrant above the amount payable therefor upon such exercise immediately prior to such increase in par value, (ii) take all such action as may be necessary or appropriate in order that the Company may validly and legally issue fully paid and nonassessable Common Shares upon the exercise of this Class F Warrant, and (iii) use its best efforts to obtain all such authorizations, exemptions or consents from any public regulatory body having jurisdiction thereof as may be necessary to enable the Company to perform its obligations under this Class F Warrant.

(c)

Before taking any action which would cause an adjustment reducing the current Exercise Price below the then par value, if any, of the Common Shares issuable upon exercise of the Class F Warrants, the Company shall take any corporate action which may be necessary in order that the Company may validly and legally issue fully paid and non-assessable shares of such Common Shares at such adjusted Exercise Price.

(d)

Before taking any action which would result in an adjustment in the number of Common Shares for which this Class F Warrant is exercisable or in the Exercise Price, the Company shall obtain all such authorizations or exemptions thereof, or consents thereto, as may be necessary from any public regulatory body or bodies having jurisdiction thereof.

(e)

The Company covenants that during the period the Class F Warrant is outstanding, it will use its best efforts to comply with any and all reporting obligations under the Securities Exchange Act of 1934, as amended.

(f)

The Company will take all such reasonable action as may be necessary (i) to maintain a Principal Market for its Common Shares in the United States and (ii) to assure that such Warrant Shares may be issued as provided herein without violation of any applicable law or regulation, or of any requirements of the Principal Market upon which the Common Shares may be listed.

(g)

The Company shall preserve and maintain its corporate existence and all licenses and permits that are material to the proper conduct of its business.

(h)

The Company will not close its shareholder books or records in any manner which prevents the timely exercise of this Class F Warrant.

6.

Exchange, Transfer or Assignment of Class F Warrant; Registration.

(a)

Each taker and holder of this Class F Warrant Certificate by taking or holding the same, consents and agrees that the registered holder hereof may be treated by the Company and all other persons dealing with this Class F Warrant Certificate as the absolute owner hereof for any purpose and as the person entitled to exercise the rights represented hereby.

(b)

The Holder agrees that it will not transfer, hypothecate, sell, assign, pledge or encumber any Class F Warrants or Warrant Shares unless such securities are registered under the U.S. Securities Act and registered or qualified under any applicable state securities laws or such transfer is affected pursuant to an available exemption from registration.

7.

Anti-Dilution Provisions.  The Exercise Price in effect at any time and the number and kind of securities purchasable upon the exercise of the Class F Warrant shall be subject to adjustment from time to time upon the happening of certain events as follows:

(a)

In case the Company shall (i) declare a dividend or make a distribution on its outstanding Common Shares in Common Shares, (ii) subdivide or reclassify its outstanding Common Shares into a greater 

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number of shares, or (iii) combine or reclassify its outstanding Common Shares into a smaller number of shares, the number of Warrant Shares shall be proportionately adjusted to reflect such dividend, distribution, subdivision, reclassification or combination. For example, if the Company declares a 2 for 1 stock split and the number of Warrant Shares immediately prior to such event was 200,000, the number of Warrant Shares immediately after such event would be 400,000.  Such adjustment shall be made successively whenever any event listed above shall occur.  

(b)

Whenever the number of Warrant Shares is adjusted pursuant to Subsection (a) above, the Exercise Price shall simultaneously be adjusted by multiplying the Exercise Price immediately prior to such event by the number of Warrant Shares immediately prior to such event and dividing the product so obtained by the number of Warrant Shares, as adjusted. If an Exercise Price has not yet been established, an adjustment thereof shall be deferred until one is established pursuant to the terms of this Class F Warrant.

(c)

No adjustment in the Exercise Price shall be required unless such adjustment would require an increase or decrease of at least five percent (5%) in such price; provided, however, that any adjustments which by reason of this Subsection (c) are not required to be made shall be carried forward and taken into account in any subsequent adjustment required to be made hereunder. All calculations under this Section 7 shall be made to the nearest cent or to the nearest one-hundredth of a share, as the case may be.

(d)

Whenever the Exercise Price is adjusted, as herein provided, the Company shall promptly cause a notice setting forth the adjusted Exercise Price and adjusted number of Shares issuable upon exercise of each Class F Warrant to be mailed to the Holder.  The Company may retain a firm of independent certified public accountants selected by the Board of Directors (who may be the regular accountants employed by the Company) to make any computation required by this Section 7, and a certificate signed by such firm shall be conclusive evidence of the correctness of such adjustment.

(e)

In the event that at any time, as a result of an adjustment made pursuant to Subsection (a) above, the Holder of this Class F Warrant thereafter shall become entitled to receive any shares of the Company, other than Common Shares, thereafter the number of such other shares so receivable upon exercise of this Class F Warrant shall be subject to adjustment from time to time in a manner and on terms as nearly equivalent as practicable to the provisions with respect to the Common Shares contained in Subsection (a), above.

(f)

Irrespective of any adjustments in the Exercise Price or the number or kind of shares purchasable upon exercise of this Class F Warrant, Class F Warrants theretofore or thereafter issued may continue to express the same price and number and kind of shares as are stated in this Class F Warrant.

(g)

In case at any time or from time to time conditions arise by reasons of action taken by the Company, which in the reasonable opinion of its Board of Directors, are not adequately covered by the provisions of Section 7 hereof, and which might materially and adversely affect the exercise rights of the Holder hereof, the Board of Directors shall appoint a firm of independent certified public accountants, which may be the firm regularly retained by the Company, which will give their opinion upon the adjustment, if any, on a basis consistent with the standards established in the other provisions of Section 7 necessary with respect to the Exercise Price then in effect and the number of Common Shares for which the Class F Warrant is exercisable, so as to preserve, without dilution, the exercise rights of the Holder.  Upon receipt of such opinion, the Board of Directors shall forthwith make the adjustments described therein.

8.

Loss or Destruction of Class F Warrant.  Upon receipt by the Company of evidence satisfactory to it (in the exercise of its reasonable discretion) of the loss, theft, destruction or mutilation of this Class F Warrant Certificate, and (in the case of loss, theft or destruction) of reasonably satisfactory indemnification, and upon surrender and cancellation of this Class F Warrant Certificate, if mutilated, the Company shall execute and deliver a new Class F Warrant Certificate of like tenor and date.

9.

Notices.  Any notice, demand or delivery authorized by this Class F Warrant Certificate shall be in writing and shall be given to the Holder or the Company, as the case may be, at its address (or telecopier number) set forth below, or such other address (or telecopier number) as shall have been furnished to the party giving or making such 

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notice, demand or delivery:

If to the Company:

GOLDRICH MINING COMPANY

2607 Southeast Blvd., Suite B211 

Spokane, WA  99223

Attention:  William Schara

Telephone No.: (509) 768-4468

Telecopier No.: (509) 695-3289

Email: wschara@goldrichmining.com

With a copy to:

DORSEY & WHITNEY LLP

Republic Plaza Building

370 Seventeenth Street, Suite 4700

Denver, CO  80202-5647

Attn:  Jason K. Brenkert, Esq.

Fax:  303-629-3450

If to the Holder: 

at the address set forth on the last page of this Class F Warrant.

Each such notice, demand or delivery shall be effective (i) if given by telecopy, when such telecopy is transmitted to the telecopy number specified herein and the intended recipient confirms the receipt of such telecopy or (ii) if given by any other means, when received at the address specified herein.  

10.

Rights of the Holder.  Prior to the exercise of any Class F Warrant, the Holder shall not, by virtue hereof, be entitled to any rights of a shareholder of the Company, including, without limitation, the right to vote, to receive dividends or other distributions, to exercise any preemptive right or any notice of any proceedings of the Company except as may be specifically provided for herein.

11.

GOVERNING LAW.  THIS CLASS F WARRANT CERTIFICATE AND ALL RIGHTS ARISING HEREUNDER SHALL BE CONSTRUED AND DETERMINED IN ACCORDANCE WITH THE INTERNAL LAWS OF THE STATE OF ALASKA, AND THE PERFORMANCE THEREOF SHALL BE GOVERNED AND ENFORCED IN ACCORDANCE WITH SUCH LAWS.

12.

Amendments; Waivers.  Any provision of this Class F Warrant Certificate may be amended or waived if, and only if, such amendment or waiver is in writing and signed, in the case of an amendment, by the Holder and the Company, or in the case of a waiver, by the party against whom the waiver is to be effective.  No failure or delay by either party in exercising any right, power or privilege hereunder shall operate as a waiver thereof nor shall any single or partial exercise thereof preclude any other or further exercise thereof or the exercise of any other right, power or privilege.  The rights and remedies herein provided shall be cumulative and not exclusive of any rights or remedies provided by law.

13.

Company Reorganization.  In the event of any sale of substantially all the assets of the Company or any reorganization, reclassification, merger or consolidation of the Company where the Company is not the surviving entity, then as a condition to the Company entering into such transaction, the entity acquiring such assets or the surviving entity, as the case may be, shall agree to assume the Company's obligations hereunder.

************

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IN WITNESS WHEREOF, the Company has duly caused this Class F Warrant to be signed by its duly authorized officer and to be dated as of ________________, 2009.

GOLDRICH MINING COMPANY

By:                                                                  

Name:                                                            

Title:                                                              

HOLDER:

______________________________

______________________________

______________________________

(Name and address)

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CLASS F WARRANT EXERCISE SUBSCRIPTION FORM

(To be executed only upon exercise of the Class F Warrant

after delivery of Warrant Exercise Notice)

To:

GOLDRICH MINING COMPANY

The undersigned irrevocably exercises the Class F Warrant for the purchase of _______________ shares (the "Shares") of Common Shares, par value $0.10 per share, of GOLDRICH MINING COMPANY (the "Company") at $______________ per Share (the Exercise Price currently in effect pursuant to the Class F Warrant).

The undersigned herewith makes payment of $_____________ (such payment being made in cash or by certified or official bank or bank cashier's check payable to the order of the Company or by any permitted combination of such cash or check), all on the terms and conditions specified in the within Class F Warrant Certificate, surrenders this Class F Warrant Certificate and all right, title and interest therein to the Company and directs that the Shares deliverable upon the exercise of this Class F Warrant be registered or placed in the name and at the address specified below and delivered thereto.

The undersigned is either (i) an “accredited investor” as defined in Regulation D under the Securities Act of 1933, as amended (the “U.S. Securities Act”), and is exercising these Class F Warrants in a transaction that does not require registration under the U.S. Securities Act or (ii) is not a U.S. Person or person in the United States and is exercising these Class F Warrants in an “off shore transaction” in accordance with the requirements of Regulation S of the U.S. Securities Act.  The terms U.S. Person, United States and off-shore transaction have the meanings set forth in Regulation S of the U.S. Securities Act.

Number of Common Shares beneficially owned or deemed beneficially owned by the Holder on the date of 

Exercise: _________________________

Check this box, if applicable:

o

The undersigned hereby represents that it has either sold the common stock to be issued hereunder or intends to sell such common stock within five (5) business days of receipt of such common stock in compliance with the Plan of Distribution set forth in the Registration Statement file under the U.S. Securities Act in respect to such common stock and in compliance with the applicable securities law.  The undersigned hereby requests that the share certificate representing the common stock be issued without a restrictive legend.

Date:                                                                

                                                                                     

(Signature of Owner)

                                                                                     

(Street Address)

                                                                                     

(City)

(State)

(Zip Code)

Securities and/or check to be issued to:                                                                                              

Please insert social security or identifying number:                                                                            

Name:                                                                                                                                                   

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Street Address:                                                                                                                                     

City, State and Zip Code:                                                                                                                   

Any unexercised portion of the Class F Warrant evidenced by the within Class F Warrant Certificate to be issued to:  

                                                                                                                                              

Please insert social security or identifying number:                                                              

Name: 

                                                                                                                               

Street Address:                                                                                                                      

City, State and Zip Code:                                                                                                    

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CLASS F WARRANT ASSIGNMENT FORM

Dated ___________ ___, _____

FOR VALUE RECEIVED, _______________________ hereby sells, assigns and transfers unto_____________________________(the "Assignee"),

(please type or print in block letters)

                                                                                                                                                              

                                                                                                                                                              

(insert address)

its right to purchase up to Common Shares represented by these Class F Warrants and does hereby irrevocably constitute and appoint _______________________ Attorney, to transfer the same on the books of the Company, with full power of substitution in the premises.

Signature:                                                                     

THE SECURITIES REPRESENTED HEREBY HAVE NOT BEEN AND WILL NOT BE REGISTERED UNDER THE UNITED STATES SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”).  THESE SECURITIES MAY BE OFFERED, SOLD, PLEDGED OR OTHERWISE TRANSFERRED IN COMPLIANCE WITH THE EXEMPTION FROM THE REGISTRATION REQUIREMENTS UNDER THE SECURITIES ACT AND ANY APPLICABLE STATE LAWS AND REGULATIONS GOVERNING THE OFFER AND SALE OF SECURITIES. 

To be completed by transferee.  

In connection with this transfer: (check one):

______

The undersigned transferee hereby certifies that (i) it is not a U.S. Person and was not offered the Class F Warrants while in the United States and did not execute this certificate while within the United States, (ii) it is not acquiring any of the Class F Warrants represented by this Class F Warrant Certificate by or on behalf of any U.S. person or person within the United States, and (iii) it has in all other respects complied with the terms of Regulation S of the United States Securities Act of 1933, as amended (the “US Securities Act”), or any successor rule or regulation of the United States Securities and Exchange Commission as presently in effect.

______

The undersigned transferee is delivering a written opinion of U.S. counsel to the effect that this transfer of Class F Warrants has been registered under the US Securities Act or are exempt from registration thereunder.

Signature:                                        

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Exhibit C

Selling Shareholder Questionnaire

C-1

GOLDRICH MINING COMPANY

SELLING SHAREHOLDER QUESTIONNAIRE

To:

GOLDRICH MINING COMPANY

2607 Southeast Blvd., Suite B211

Spokane, WA 99223

Complete and Return with Subscription Agreement

Capitalized terms used herein but not otherwise defined shall have the meaning set forth in that certain Subscription Agreement, by and between Goldrich Mining Company, an Alaska corporation (the “Company”), and the Subscribers thereto.  This Questionnaire is being delivered to you in connection with a registration statement to be filed with the United States Securities and Exchange Commission.  Your securities will not be registered unless you complete this Questionnaire and return it as instructed.

A.

BACKGROUND INFORMATION

Name:                                                                                                                                                                               

Business Address:                                                                                                                                                          

(Number and Street)

                                                                                                                                                                                        

(City)

(State)

(Zip Code)

Telephone Number:                                                                                                                                                         

If a corporation, partnership, limited liability company, trust or other entity:

Type of entity:                                                                                                                                                    

State of formation:                                                

Date of formation:                                                

Social Security or Taxpayer Identification No.                                                                                                                

Email address of contact person:                                                                                                                                      

Current ownership of securities of the Company:

____Common Shares

Options or warrants to purchase _______ Common Shares (if any)

Number of Shares you are requesting to be registered in the Registration Statement:

_____________ Common Shares (include shares underlying warrants)

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BENEFICIAL OWNERSHIP INFORMATION: Please describe the beneficial ownership of the shares and/or warrants owned by you or your organization.  If the undersigned is a partnership, limited liability company or similar entity, please identify the individual or individuals with ultimate voting and dispositive power over such shares and/or warrants, typically the investment manager or investment advisor with primary responsibility for this investment.  This information is available from your compliance officer or general counsel.  THE COMPANY WILL NOT BE ABLE TO REGISTER YOUR SECURITIES WITHOUT THIS IMPORTANT INFORMATION.

Exception: This information need not be provided if the undersigned is a publicly traded company.

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

Have you or your organization had any position, office or other material relationship within the past three years with the Company or its affiliates?

[   ] Yes

[   ] No

If yes, please indicate the nature of any such relationships below:

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

If you, any of your associates, or any member of your immediate family had or will have any direct or indirect material interest in any transaction or series of transactions to which the Company or any of its subsidiaries was a party at any time since January 1, 2007, or in any currently proposed transactions or series of transactions in which the company or any of its subsidiaries will be a party, in which the amount involved exceeds $60,000, please specify (a) the names of the parties to the transaction(s) and their relationship to you, (b) the nature of the interest in the transaction, (c) the amount involved in the transaction, and (d) the amount of the interest in the transaction.  If the answer is “none”, please so state.

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

Are you (i) an FINRA Member (see definition), (ii) a Controlling (see definition) shareholder of an FINRA Member, (iii) a Person Associated with a Member of the FINRA (see definition), or (iv) an Underwriter or a Related Person (see definition) with respect to the proposed offering; or (b) do you own any shares or other securities of any FINRA Member not purchased in the open market; or (c) have you made any outstanding subordinated loans to any FINRA Member? IN RESPONDING TO THIS QUESTION, INDICATE WHETHER OR NOT YOU ARE A BROKER DEALER OR IF YOU ARE AFFILIATED WITH A BROKER DEALER, AND IF SO, STATE THE NATURE OF YOUR AFFILIATION.

[   ] Yes

[   ] No

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If “yes,” please describe below

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

                                                                                                                                                                                         

FINRA Member.  The term “FINRA member” means either any broker or dealer admitted to membership in the Financial Industry Regulatory Authority (“FINRA”).  

Control.  The term “control” (including the terms “controlling,” “controlled by” and “under common control with”) means the possession, direct or indirect, of the power, either individually or with others, to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract, or otherwise. 

Person Associated with a member of the FINRA.  The term “person associated with a member of the FINRA” means every sole proprietor, partner, officer, director, branch manager or executive representative of any FINRA Member, or any natural person occupying a similar status or performing similar functions, or any natural person engaged in the investment banking or securities business who is directly or indirectly controlling or controlled by a FINRA Member, whether or not such person is registered or exempt from registration with the FINRA pursuant to its bylaws.  

Underwriter or a Related Person.  The term “underwriter or a related person” means, with respect to a proposed offering, underwriters, underwriters’ counsel, financial consultants and advisors, finders, members of the selling or distribution group, and any and all other persons associated with or related to any of such persons. 

IN WITNESS WHEREOF, the undersigned has executed this Questionnaire this ____ day of ________, 200__, and declares under oath that it is truthful and correct.

                                                                                                   

Printed Name

By:                                                                                             

Its:                                                                                             

By:                                                                                             

Name:                                                                                        

Title:                                                                                           

 

Return each completed and signed Questionnaire with your Subscription Agreement.

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Schedule I

Wire Transfer InstructionsYukon-Nevada Gold Corp. - Exhibit 4.1 - Filed by newsfilecorp.com

Exhibit 4.1 – 2007 Stock Option Plan

1.           
Purpose 

1.1.                      
The purpose of the Incentive Stock Option Plan (the "Plan") is
to promote the profitability and growth of YUKON-NEVADA GOLD CORP. (the
"Company") by facilitating the efforts of the Company and its
subsidiaries to obtain and retain key individuals. The Plan provides an
incentive for and encourages ownership of the Company's common shares
(“Shares”) by its key individuals so that they may increase their stake
in the Company and be incentized by increases in the value of the Company's
Shares. 

2.           
Administration 

2.1.                      
The Plan will be administered by the Company's Board of Directors (the
"Board") or a committee of the Board (“Committee”). In the event
the Plan is administered by a Committee, the Committee shall comprise not fewer
than three persons, each of whom must be “independent” within the meaning of
Multilateral Instrument 52-110, Audit Committees, adopted by the Canadian
Securities Administrators. Except as to the composition of the Committee, where
used herein, the term “Committee” will also include the Board. 

2.2.                      
The Committee will be authorized, subject to the provisions of the Plan, to
adopt such rules and regulations which it deems consistent with the Plan's
provisions and, in its sole discretion, to grant options ("Options") to
purchase Shares of the Company pursuant to the Plan. The Committee may authorize
one or more directors, officers or employees of the Company or an individual
(including an individual whose services are contracted through a personal
holding corporation) with whom the Company or a subsidiary has a contract for
substantial services (a “Consultant”) to execute, deliver and receive
documents on behalf of the Committee. 

3.           
Eligibility 

3.1.                      
All directors, officers, Consultants and employees of the Company and its
subsidiaries will be eligible to receive Options. 

3.2.                      
Nothing in the Plan or in any Option shall confer any right on any
individual to continue in the employ of or in any capacity with the Company or
its subsidiaries or will interfere in any way with the right of the Company or
subsidiaries to terminate at any time the employment or other capacity of a
person who is an optionee ("Optionee") under an Option. 

4.           
Shares Subject to Option 

4.1.                      
The Shares to be optioned under the Plan will be authorized but
unissued common shares without par value of the Company. 

4.2.                      
Subject to adjustment as provided for herein, the number of Shares available for
purchase pursuant to Options granted pursuant to this Plan will not exceed 10%
of the number of Shares which are issued and outstanding on the particular date
of grant of Options including: (a) the existing Shares currently subject to
outstanding Options as of the date of this Plan which were granted prior to the
implementation of this Plan and which, by the implementation of this Plan, are
covered under this Plan; and (b) the additional stock options which may be
granted and exchanged with holders of stock options of Queenstake Resources Ltd.
(“Queenstake”) as a result of the Company’s business combination by plan of
arrangement with Queenstake.

4.3.                      
Any Shares subject to an Option which for any reason is cancelled or
terminated without having been exercised, shall again be available for grant
under the Plan. No fractional shares shall be issued. Reference should be made
to section 23.4 for the manner in which fractional share values will be treated.

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4.4.                      
The Board may, at any time, without further approval by the
shareholders of the Company, amend the Plan or any Option granted hereunder in
such respects as it may consider advisable and, without limiting the generality
of the foregoing, it may do so to: 

	(a) 	
      amend typographical, clerical and grammatical
    errors;

	 	 
	(b) 	
      reflect changes to applicable securities laws;

	 	 
	(c) 	
      change the termination provisions of Options or the Plan
      which do not entail an extension beyond the original expiry
date;

	 	 
	(d) 	
      include the addition of a cashless exercise feature,
      payable in cash or securities;

	 	 
	(e) 	
      ensure that the Options granted under the Plan will
      comply with any provisions respecting the income tax and other laws in
      force in any country or jurisdiction of which a Participant to whom an
      Option has been granted may from time to time be resident or a citizen;
      and

	 	 
	(f) 	
      reduce the exercise price of an Option for an Optionee
      who is not an insider of the Company.

4.5.                      
The number of Shares issuable to insiders of the Company, at any time, under all
security-based compensation arrangements, cannot exceed 10% of the total issued
and outstanding (as to a maximum of 5% with respect to any one individual)
Shares; and

4.6.                      
The number of Shares issued to insiders, within any one year period, under all
security-based compensation arrangements, cannot exceed 10% of the Company’s
issued and outstanding Shares. This provision applies to all types of
security-based compensation. 

5.           
Granting of Options 

5.1.                      
The Committee may from time to time at its discretion, subject to the
provisions of the Plan, determine those eligible individuals to whom Options
will be granted, the number of Shares subject to such Options, the dates on
which such Options are to be granted and the expiration of such Options. 

5.2.                      
The Committee may, at its discretion, with respect to any Option,
impose additional terms and conditions, including conditions for the vesting of
Options, which are more restrictive on the Optionee than those provided for in
the Plan. 

5.3.                      
Each Option will be evidenced by a written agreement between, and
executed by, the Company and the individual containing terms and conditions
established by the Committee with respect to such Option and will be consistent
with the provisions of the Plan. 

6.           
Option Price 

6.1.                      
The price per Share at which Shares may be purchased upon the exercise
of an Option (the "Option Price") will not be lower than the last
recorded sale of a board lot of Shares on the Toronto Stock Exchange (the
“TSX”) during the trading day immediately preceding the date of granting
of the Option or, if there was no such sale, the weighted average trading price
on the TSX of the Shares for the five trading days immediately preceding the
date on which the Option is granted. 

7.           
Term of Option 

7.1.                      
The maximum term of any Option will be 10 years. 

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7.2.                      
The Option Price must be paid in full at the time of exercise of the
Option and no Shares will be delivered until full payment is made. 

7.3.                      
An Optionee will not be deemed the holder of any Shares subject to his
Option until the Shares are delivered to him. 

8.           
Transferability of Options 

8.1.                      
An Option may not be assigned. During the lifetime of an Optionee, the
Option may be exercised only by the Optionee. 

9.           
Termination of Employment 

9.1.                      
Upon termination of employment or other capacity with the Company for
any reason except death or retirement, or failure of re-election as a director,
or failure to be re-appointed an officer of the Company, an Optionee may, at any
time within 90 days after the date of termination but not later than the date of
expiration of the Option, exercise the Option to the extent the Optionee was
entitled to do so on the date of termination. Any Option or portions of Options
of terminated individuals not so exercised will terminate and will again be
available for future Options under the Plan. A change of employment or capacity
with the Company will not be considered a termination so long as the Optionee
continues to be employed or engaged by the Company or its subsidiaries in a
capacity eligible to receive Options under this Plan. 

10.          Death

10.1.                  
Notwithstanding any other provision of the Plan, if any Optionee dies holding an
Option which has not been fully exercised, his personal representative, heirs or
legatees may, at any time within 60 days of grant of probate of the will, or
letters of administration of the estate of the decedent, or within one year
after the date of such death, whichever is the lesser time (notwithstanding the
normal expiry date of the Option) exercise the Option with respect to the
unexercised balance of the Shares subject to the Option. 

11.          Retirement

11.1.                  
Notwithstanding any other provision of the Plan, if any Optionee shall retire,
or terminate his employment or other capacity with the Company with the consent
of the Board under circumstances equating retirement, while holding an Option
which has not been fully exercised, such Optionee may exercise the Option at any
time during the unexpired term of the Option. 

12.          Changes
in Shares 

12.1.                   In
the event the authorized share capital of the Company as presently constituted
is consolidated into a lesser number of Shares or is subdivided into a greater
number of Shares, the number of Shares for which Options are outstanding will be
decreased or increased proportionately as the case may be, and the Option Price
per Share will be adjusted accordingly and the Optionees will have the benefit
of any stock dividend declared during the period within which the said Optionee
held his Option. Should the Company amalgamate or merge with any other company
or companies (the right to do so being hereby expressly reserved) whether by way
of arrangement, sale of assets and undertakings or otherwise, then and in each
such case the number of shares of the resulting corporation to which an Option
relates will be determined as if the Option had been fully exercised prior to
the effective date of the amalgamation or merger and the Option Price per Share
will be correspondingly increased or decreased, as applicable. 

13.          Effect
of a Take-Over Bid 

13.1.                   If
a bona fide offer (an "Offer") for Shares is made to the
Optionee or to shareholders of the Company generally or to a class of
shareholders which includes the Optionee, which Offer, if accepted in
whole or in part, would result in the offeror becoming a control
person of the Company, within the meaning given to "control person" in the Securities Act (British Columbia), the Company will, immediately upon
receipt of notice of the Offer, notify each Optionee of full particulars of the
Offer, whereupon all Shares subject to such Option will become vested and the
Option may be exercised in whole or in part by the Optionee so as to permit the
Optionee to tender the Shares received upon such exercise, pursuant to the
Offer. However, if: 

4 

	(a) 	
      the Offer is not completed within the time specified
      therein; or

	 	 
	(b) 	
      all of the Shares tendered by the Optionee pursuant to
      the Offer are not taken up or paid for by the offeror in respect
      thereof,

then the Shares received upon such exercise, or in the case of
Section 13.1(b) hereof, the Shares that are not taken up and paid for, may be
returned by the Optionee to the Company and reinstated as authorized but
unissued Shares and with respect to such returned Shares, the Option will be
reinstated as if it had not been exercised and the terms upon which such Shares
were to become vested pursuant to this Section will be reinstated. If any Shares
are returned to the Company under this Section 13, the Company will immediately
refund the exercise price to the Optionee for such Shares. 

14.          Acceleration
of Expiry Date 

14.1.                   If
an Offer is made by an offeror at any time when an Option granted under the Plan
remains unexercised, in whole or in part, the Directors may, upon notifying each
Optionee of full particulars of the Offer, declare all Shares issuable upon the
exercise of Options granted under the Plan to be vested and declare that the
Expiry Date for the exercise of all unexercised Options granted under the Plan
be accelerated so that all Options will either be exercised or will expire prior
to the date upon which Shares must be tendered pursuant to the Offer. 

15.          Effect
of a Change of Control 

15.1.                   If
a Change of Control, as hereinafter defined, occurs, all Shares subject to each
outstanding Option will become vested, whereupon such Option may be exercised in
whole or in part by the Optionee. 

15.2.                   “Change
of Control” means the acquisition by any person, or by any person and a
Joint Actor, whether directly or indirectly, of voting securities as defined in
the Securities Act (British Columbia) of the Company, which, when added
to all other voting securities of the Company at the time held by such person or
by such person and a Joint Actor, totals for the first time not less than 30% of
the outstanding voting securities of the Company or the votes attached to those
securities are sufficient, if exercised, to elect a majority of the Board of
Directors of the Company. "Joint Actor" means a person acting "jointly or
in concert with" another person as that phrase is interpreted in the
Securities Act (British Columbia). 

16.          Exchange
Policy Applies 

16.1.                   The
Plan and the granting and exercise of any Options hereunder are also subject to
such other terms and conditions as are set out from time to time in the Policies
of the TSX and any securities commission having authority, and the Policies of
the TSX will be deemed to be incorporated into and become a part of the Plan. In
the event of an inconsistency between the provisions of the Policies of the TSX
and of the Plan, the provisions of the Policies of the TSX will govern. 

17.          Cancellation
and Re-granting of Options 

17.1.                   The
Committee may, with the consent of the Optionee, cancel an existing Option, and
re-grant the Option at an Option Price determined in the same manner as provided
in Section 6 hereof, subject to the prior approval of the TSX. 

5 

18.          Amendment
or Discontinuance 

18.1.                   The
Board may alter, suspend or discontinue the Plan, but may not, without the
approval of the shareholders of the Company, make any alteration which would (a)
increase the aggregate number of Shares subject to Option under the Plan except
as provided in Section 12 or (b) decrease the Option Price except as provided in
Section 17. Notwithstanding the foregoing, the terms of an existing Option may
not be altered, suspended or discontinued without the consent in writing of the
Optionee. 

19.          Extension
of Expiry Date of Stock Options Expiring During a Blackout Period 

19.1.                   The
expiry date of outstanding Options held by Optionees which may expire during a
restricted trading period, imposed by the Company in accordance with applicable
securities laws (a "Blackout Period"), will be extended for a period of 10
business days commencing on the first business day after the expiry date of the
Blackout Period to provide such Optionees with an extension to the right to
exercise such Options. 

20.          Interpretation

20.1.                   The
Plan will be construed according to the laws of the Province of British
Columbia. 

21.          Liability

21.1.                   No
member of the Committee or any director, officer, Consultant or employee of the
Company will be personally liable for any act taken or omitted in good faith in
connection with the Plan. 

22.         
Representation by Participants 

22.1.                   Each
option agreement shall provide that upon each exercise of an Option, the
Optionee (including for the purposes of this section 22 each other person who,
pursuant to sections 9, 10 and 11 hereof, may purchase Shares under an Option
granted to a director, officer, Consultant or employee of the Company) shall, if
so requested by the Company, represent and agree in writing that: 

	(a) 	
      the person is, or the Optionee was, a director, officer,
      Consultant or employee of the Company or a director, officer, Consultant
      or employee of an associated, affiliated, controlled or subsidiary company
      and has not been induced to purchase the Shares by expectation of
      employment or continued employment;

	 	 
	(b) 	
      the person is purchasing the Shares pursuant to the
      exercise of such Option as principal for the Optionee’s own account (or if
      such Optionee is deceased, for the account of the estate of such deceased
      Optionee);

	 	 
	(c) 	
      the person will, prior to and upon any sale or
      disposition of any of the Shares purchased pursuant to the exercise of
      such Option, comply with all applicable securities laws and any other
      federal, provincial or state laws or regulations to the extent that such
      laws or regulations are applicable to such sale or disposition;
  and

	 	 
	(d) 	
      such Optionee (or such other person) will not offer, sell
      or deliver any of the Shares purchased pursuant to the exercise of such
      Option, directly or indirectly, in the United States or to any citizen or
      resident of, or any corporation, partnership or other entity created or
      organized in or under the laws of, the United States, or any estate or
      trust the income of which is subject to United States federal income
      taxation regardless of its source, except in compliance with United States
      federal and state securities laws. The Optionee acknowledges that the
      Company has the right to place any restriction or legend on any securities
      issued pursuant to this Plan including, but in no way limited to placing a
      legend to the effect that the securities have not been registered under
      the United States Securities Act of 1933 and may not be offered or
      sold in the United States unless registration or an exemption from
      registration is available.

6 

	(e) 	
      The Company may employ other procedures and require
      further documentation from an Optionee to ensure compliance with all
      applicable laws.

	 	 
	(f) 	
      The issue and sale of Shares pursuant to any Option
      granted under the Plan is conditioned on such issue and sale being made in
      compliance with applicable securities laws, and the Company shall have no
      obligation to issue or sell any Shares pursuant to the exercise of any
      Option unless the Board determines in its sole discretion that such issue
      and sale will be made in compliance with applicable securities
  laws.

23.         
Effective Date 

23.1.                  
This Plan will supersede and replace all previous stock option plans on
May 18, 2007. This Plan is subject to the approval of: 

	(a) 	
      TSX; and

	 	 
	(b) 	
      the shareholders of the Company, given by the affirmative
      vote of a majority of the votes attached to the Shares of the Company
      entitled to vote and represented and voted at an annual or special meeting
      of the holders of such Shares held, among other things, to consider and
      approve the Plan,

	 	 
	(c) 	
      and until such approvals are obtained Options granted
      pursuant to the Plan shall not be exercisable.

24.         
Miscellaneous 

24.1.                  
Nothing contained herein shall prevent the Board from adopting other or
additional compensation arrangements, subject to any required regulatory or
shareholder approval. 

24.2.                  
Nothing contained in the Plan nor in any Option granted thereunder
shall be deemed to give any Optionee any interest or title in or to any Shares
or any rights as a shareholder of the Company or any other legal or equitable
right against the Company whatsoever other than as set forth in the Plan and
pursuant to the exercise of any Option. 

24.3.                  
The Plan does not give any director, officer, Consultant or employee of the
Company the right or obligation to become or to continue to serve as a director,
officer, Consultant or employee of the Company, as the case may be, of the
Company or any of its subsidiaries. The awarding of Options to any director,
officer, Consultant or employee of the Company is a matter to be determined
solely in the discretion of the Board. The Plan shall not in any way fetter,
limit, obligate, restrict or constrain the Board with regard to the allotment or
issue of any Shares or any other securities in the capital of the Company or any
of its subsidiaries other than as specifically provided for in the Plan. 

24.4.                  
No fractional Shares shall be issued upon the exercise of Options and,
accordingly, if a Optionee would become entitled to a fractional Share upon the
exercise of an Option, such Optionee shall only have the right to purchase the
next lowest whole number of Shares and no payment or other adjustment will be
made with respect to the fractional interest so disregarded. 

24.5.                  
The grant of an Option shall be conditional upon the director, officer,
Consultant or employee of the Company to whom the Option is granted completing,
signing and delivering to the Company all documents as may be required by the
regulatory authorities having jurisdiction. 

25.         
Shareholder Approval 

25.1.                  
The Plan, as approved by the shareholders of the Company, will terminate unless
it is approved by the shareholders of the Company at the annual general meeting
held every three years following the initial approval.

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