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Retention Licence Application Form

Mineral Resources (Sustainable Development) Act 1990 (MRSDA)

ALL information required by Schedule 5 of the Mineral Resources (Sustainable Development) (Mineral Industries) Regulations 2013 must be provided or the application is invalid. Section 15 of the MRSDA also sets out additional requirements for Retention Licences.

The Ministerial Guidelines for describing a mineral resource must also be followed in making an application for a retention licence.

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

A map of scale 1:25,000 or larger must be attached clearly showing the boundaries of private land and Crown land.

Attach information that demonstrates that the area of the land applied for is only that land which may be required for the purpose of mining a mineral resource in the future.

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: Does the application area lie within an Exploration Licence (EL) or a Prospecting Licence (PL) either granted or applied for?

Give licence number

If YES please tick the appropriate box below:

(The application is invalid if you cannot tick one of these questions below)

or

Question 6: Estimated expenditure and activities schedule for the life of the licence

Term of Licence being applied for: Years

  Geological Work
(i.e. infill, bulk sampling)
Project Development
(PFS, Ancillary Studies, Approvals)
Expenditure ($)
Year 1  
Year 2  
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
Year 9
Year 10
 

Total RL Expenditure:

 

Projected CAPEX should full scale mining occur:

Note: Only include activities and expenditure for the number of years you are applying for.

Projected extraction rate: (Mtpa/Wells/oz pa/tpa)

Attach information that demonstrates that the proposed expenditure is commensurate with the proposed program of work (refer Question 14 regarding program of work)

Question 7: 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 statements)

Assets $
Professional expertise in lieu of expenditure
Line of credit from a recognised financial institution
Prospectus (must be underwritten)
Total
Liabilities $
Expenditure commitment for two years
Total

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

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

Assets $
Bank Statement (current)

Professional expertise in lieu of expenditure (refer to application kit)

Line of credit from a recognised financial institution
Prospectus (must be underwritten)
List of plant and equipment owned by the applicant

Shares Certificates - value of listed shares held in other entities at current market price

Total
Liabilities $
Expenditure commitment for other granted tenements (Victoria and elsewhere for the next two years)

Expenditure required on this application for the first two years

Total
Net Financial Position $
Liabilities subtracted from Assets

Note: All applicants must provide a current bank statement.

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

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

Question 8: Expertise of person(s), including the applicant, undertaking the retention licence activities
  Name Qualifications Employee of applicant?
1.
Yes No
2.
Yes No

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 9: Indicate your experience in exploration and mining activities

Question 10: Indicate your experience in project evaluation and development activities

Question 11: 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 business.

Question 12: Mineralisation Report

The mineralisation report must be submitted with the application.
The mineralisation report must include the exploration results in relation to the described mineral resource, including the:

The mineralisation report must also include, in accordance with the Ministerial guidelines, information to demonstrate that:

Refer to Guidelines for Description of a Mineral Resource in a Mining Licence or a Retention Licence Application.

Question 13: Competent Person

The mineralisation report must be prepared by a competent person.
The following information must also be submitted with the mineralisation report as evidence that it has been prepared by a competent person:

Question 14: Details of the program of work

Attach a program of work that supplements the work program summary detailed in question 6 by including the following information:

Refer to Retention Licence Application Kit and the Retention Licence guidelines for specific details of Mineralisation Report and program of work requirements.

Question 15: Primary mineral to which the application relates

Gold
Silver
Platinum
Antimony
Diamonds
Mineral sands
Kaolin/Clay
Base metals (copper, lead, zinc)
Gypsum
Coal
Other (specify)

Question 16: Description of mineral resource

Section 15(1BB) of the MRSDA requires that the application describes the mineral resource in accordance with the guidelines issued by the Minister. Attach a description of the mineral resource, in accordance with the Ministerial guidelines and indicate whether that description refers to a:

Question 17: Preferred annual reporting date (choose one of the following dates)

Question 18: Application Fee

Application for Retention Licence fee of $

Note: The application must be accompanied by the prescribed fee. Refer Fees and charges

Question 19: Survey of land applied for

Section 15(1BH) of the MRSDA requires that the application must include a survey of the boundary of the land proposed to be covered by the licence in accordance with Division 3A.

Attach a survey of the land proposed to be covered by the licence:    

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 DEDJTR 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.

Opening hours: Monday to Friday 9:00am to 4:30pm.

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 MRSDA or a relevant Act. Limited information may be available to the public for the purpose of land use advice.

You must submit this application to:

The Earth Resources Information Centre
Level 15, 1 Spring Street, Melbourne, 3000

Opening hours: Monday to Friday 9:00am to 4:30pm

(GPO Box 2392, Melbourne VIC 3001)

Ranking is given according to the day the application is received by the Earth Resources information Centre.

Office Use Only

Date Received:

Delivered: In person / By post

Checked by:

Retention Licence no:

District: