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Exploration Licence Application Form

Mineral Resources (Sustainable Development) Act 1990 (MRSDA)

ALL information required by Schedule 2 of the Mineral Resources (Sustainable Development) (Mineral Industries) Regulations 2013 (MRSDMIR) must be provided or the application is invalid. Section 15 of the MRSDA also sets out additional requirements for Exploration Licences.

Question 1. Name and address of applicant(s) (if the applicant is a company, the registered address of the company)

(Do not show a Post Box Number. Must be registered office address if a company.)

(Do not show a Post Box Number. Must be registered office address if a company.)

Note: If more than two applicants please attach details on a separate page.

Contact details and correspondence address (if not as above):

Note: ALL applicants (or the authorised agent) must sign at end of application.

Question 2: Applicant Company details

If the applicant is a company, please attach the following items to the application.

Question 3: Description of application area
Question 4: Native Title

If the application includes Crown land, indicate which of the following options will be utilised to comply with the Commonwealth Native Title Act 1993 (NTA) or the Traditional Owners Settlement Act 2010 (TOSA).

You must answer this question now if the application includes Crown land. (Refer to Application Kit)

Question 5: Estimated annual expenditure for each year of the licence

Question 6. Evidence of financial capacity to fund the estimated expenditure

Please ensure that supplied financial information is not more than 6 months old.

1. Company (with audited financial report):

Assets: $
Liabilities:
Net Financial Position:

Note: All companies must attach their most recent audited financial report. All fields must be completed. Put N/A if not applicable.

2. Individual/Company (without audited financial report):

Assets:
Liabilities:
Net Financial Position:

Note: All applicants must provide a current bank statement.

List of plant & equipment can only be included provided it is owned by the applicant and it is to be used for activities on this application.

All fields must be completed. Put N/A if not applicable.

Question 7: Expertise of person(s), including the applicant, undertaking the exploration and/or mining program
  Name Qualifications Employee of applicant?
1.
Yes No
2.
Yes No

Note: If the person is not an employee of the applicant you must attach evidence that he/she has agreed to assist in the proposed work program.

Question 8: Indicate your experience in exploration or mining activities or both

Question 9: Indicate with a tick whether any of the following apply to the applicant or associate

If one or more of the above are applicable to either the applicant or an associate of the applicant attach details outlining -

  • the name of the party and their relationship to the applicant;
  • the nature of the offence;
  • when the offence was committed; and
  • the penalty imposed (if applicable).

Note - an Associate is defined as a director, partner, trustee, executive officer, secretary or any other officer or person associated or connected with the ownership, administration or management of the applicant's (or licensee's) business.

Question 10: Primary mineral to which the application relates

Primary mineral to be explored (tick only 1 box):

Secondary minerals to be explored:   

Question 11: Work program details for each year of the licence

The program of work should include:

Indicate the nature of targeted mineralisation (if known):

Refer to the Exploration Licence Application Kit for specific details of the program of work requirements.

Note: Reconnaissance exploration and other low impact exploration does not require a work plan. However, where a work plan is required the work plan must contain the details specified in Schedule 14 of the MRSDMIR.

Question 12: Preferred annual reporting date (Choose one of the following dates)

Question 13: Licence term required

An exploration licence may be granted for a maximum period of 5 years or a lesser period as determined by the Minister.

Question 14: Application Fee for the Exploration Licence

Note: The application must be accompanied by the prescribed fee. Refer Energy & Earth Resources fees and charges

Applicant's Declaration

I/We declare that to the best of my/our knowledge, all the information I/we have given is true and correct.

1. Name:
Position:
Signature:
Date:
2. Name:
Position:
Signature:
Date:
Attachments Checklist

Indicate with a tick, the attachments you are submitting with the application:

Privacy Statement

Personal information provided by you for the purpose of your application and any related purpose (including the issue of a licence) is collected, used and stored by the department to assist in the performance of duties under the MRSDA.

You have the right of access to this information by contacting the Earth Resources Information Centre, Department of Economic Development, Jobs, Transport and Resources, Level 15, 1 Spring Street, Melbourne VIC 3000

The information may be disclosed to the Victoria Police, the Australian Securities and Investments Commission and other government organisations for the purpose of administering or enforcing the Act or a relevant Act. Limited information may be available to the public for the purpose of land use advice.

Office Use Only

Date received:

Delivered: In person / By post

Checked by:

Exploration Licence no:

District:
YOU MUST SUBMIT THIS
APPLICATION TO
THE EARTH RESOURCES
INFORMATION CENTRE,
LEVEL 15, 1 SPRING ST
MELBOURNE VICTORIA 3000
(GPO BOX 2392,
MELBOURNE VICTORIA 3001)
RANKING IS GIVEN ACCORDING TO
THE DAY THE APPLICATION IS RECEIVED
BY
THE EARTH RESOURCES INFORMATION CENTRE