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Extractive Industries Work Authority Application Form

Disclaimer: Please note that after completing this form, it must be printed, signed and submitted. This form cannot be submitted online.

Mineral Resources (Sustainable Development) Act 1990

  • All items must be completed for the application to be considered.
  • If you have any queries please contact your Tenements Officer in the Earth Resources Regulation Branch.
  • Return completed form to your Tenements Officer.

1. Applicant information

(Applications can only be made in the name of individual/s or a company. Applications cannot be made under trading names.)


Work Authority Number:
Surname or Company Name:
Given name(s):
ACN if Company:
Contact Person:
Postal Address:
Physical Address:
(Not a PO box. Must be
registered office address
if a company)
Telephone:
Fax:
Mobile:
Email:

2. Description of Land (Checklist)

Land Status:

3. Details of Operation

Please tick the boxes below if relevant

Note: If all the above boxes are ticked no Work Plan is required however, the Work Authority will be subject to operating in accordance with the "Code of Practice for Small Quarries".


is a Cultural Heritage Management Plan (CHMP) required?
is a copy of an approved CHMP attached?

Note: if a CHMP is required, DEDJTR cannot grant a Work Authority until evidence is provided that a CHMP has been approved.

4. Crown Land Minister's Consent (if applicable)


5. Other Consents


6. Rehabilitation Bond

Note: the Rehabilitation Bond must be supplied in the form of a Bank Guarantee (refer to the Departmental Policy for Rehabilitation Bonds)

7. Public Liability Insurance

Do you hold current public liability insurance for this operation?

8. Planning Permit

Please tick the appropriate box

9. Work Plan fee

Contact us for current fees and charges.


10. Work Authority Fee

Contact us for current fees and charges.


11. Applicant signature

Signature:
Signature:

Note:

* Refer to section 127 of the Corporations Act 2001 for requirement to execute a document by a company. * Application made and submitted by persons acting on behalf of another party must provide written evidence that they are acting on behalf of that party.

Privacy Statement

The personal information on this form, and any authority that is issued following processing of this form, will be stored and used by the Department of Economic Development, Jobs, Transport and Resources for the purposes of administering the Mineral Resources (Sustainable Development) Act 1990 (the Act). You have the right of access to this information by contacting the Earth Resources Information Centre, Level 15, 1 Spring Street, Melbourne Victoria 3000. The information may be disclosed to another government organisation for the purpose of administering or enforcing the Act or a relevant Act, and to the public for the purpose of land use advice.