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Transfer of extractive industry work authority

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

Subject to obtaining the consent of the Minister under provisions of the Mineral Resources (Sustainable Development) Act 1990, I/We the Work Authority Holder(s) HEREBY TRANSFER TO the Transferee(s) described here, all rights and interest in this Authority AND THE TRANSFEREE HEREBY ACCEPTS the said transfer and holds itself responsible for compliance with the Mineral Resources(Sustainable Development) Act 1990 and the Regulations and the terms and conditions under which the said Authority is granted.

Name of Work Authority Holder:

1
2
3
4

Address of transferor(s):

(Cannot be PO Box. Must be registered office address if a company)

Transferor(s) Affix Company seal where applicable

Signature
Signature
Signature
Signature
Signature
Signature
Signature

Name of Work Authority Holder (Transferee(s)):

(If required, please attach a separate page for any additional transferee names)

1.
2.
3.
4.

Address of transferee(s):

(Cannot be PO Box. Must be registered office address if a company)

Transferee(s) Affix Company seal where applicable

Signature
Signature
Signature
Signature
Signature
Signature
Signature

20

To be completed by the proposed transferee

Contact details and correspondence address

Privacy Statement

The personal information on this form, and any authority that is issued following processing of this form, will be stored and used 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 Business Centre, Level 16, 1 Spring Street, Melbourne VIC 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.