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    • Exploration Licence Application Kit
    • Exploration Licence Application Form
    • Guidance Note on Reportable Events for Mineral and Extractive Operations
    • Mining Licence Application Kit
    • Mining Licence Application Form
    • Prospecting Licence Application Kit
    • Prospecting Licence Application Form
    • Retention Licence Application Kit
    • Retention Licence Application Form
    • Schedule 7 Notice of Exploration or Retention Licence Application
    • Notice of Intention to Commence Exploration Work on an Exploration, Mining, Prospecting or Retention Licence
    • Standard Work Plan Guidelines
    • Area Work Plan Guidelines
    • Schedule 10 Application for Renewal of Exploration Licence
    • Exploration Licence Renewal Requirements
    • Amalgamation Relinquishment Policy
    • Instrument of Transfer and Questionaire
    • Exploration Reporting Guidelines
    • Schedule 8 Notice of Application for a Mining or Prospecting Licence
    • Statement of Economic Significance
    • Marking Out and Survey Requirements
    • Notice of Intention to Markout
    • Survey Standards
    • Work Plan, Planning Consent and Other Requirements for the grant of a Work Authority on a Mining Licence or a Prospecting Licence
    • Mining Licence Worksite Management
    • Schedule 13: Mining
    • Schedule 13A: Prospecting
    • Work Plan - Guidelines for a Mining Licence
    • Schedule 9 Mining Licence Renewal Application Form
    • Mining Licence Requirements for Renewal
    • Schedule 11: Notice of Licence Renewal
    • Infringement Notice Requirements
    • Schedule 15: Annual Activity & Expenditure Return
    • Schedule 15 Statutory Guide
    • Exploration Work on a Mining or Prospecting Licence
    • Application for Work Authority and Notice of Intention to Commence Work on a Mining or Prospecting Licence
    • Schedule 10A: Application for Renewal of Retention Licence
    • Schedule 5: Application for Tourist Fossicking Authority
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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 Development Regulations 2002 (MRDR) 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)

1. Surname or Company name:

ABN (if applicable):

Given name (s):

Mr/Mrs/Ms:

Date of Birth:

Number and street name:

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

City:

State:

Postcode:

2. Surname or Company name:

ABN (if applicable):

Given name (s):

Mr/Mrs/Ms:

Date of Birth:

Number and street name:

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

City:

State:

Postcode:

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

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

Applicant Employee Agent (Please tick one)

Name:

Position (if employee):

Address for correspondence:

Telephone:

Fax:

Email

Project name for this tenement (optional):

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.

a list of the company directors and their dates of birth; and a copy of the certificate of registration of the company.

Question 3: Description of application area

1:100,000 Map Names(s):

Area (sq km)

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).

Excise all Crown land except those areas where native title has been extinguished (such as Roads and Road Reserves); Comply with the Right to Negotiate provisions of the NTA; Reach an Indigenous Land Use Agreement under the NTA; Comply with the relevant land use activity agreement under the TOSA (where applicable).

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

Question 5: Estimated expenditure for first 2 years and for the term of the licence

Year 1

Year 2

Term 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:	$
Net equity (obtained from balance sheet)
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
Net Financial Position:
Liabilities subtracted from Assets

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:
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 applicant
Shares Certificates - value of listed shares held in other entities at current market price (selling)
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 & 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 and/or mining activities

I/We currently or have previously held a minerals tenement in Victoria (within last 5 years) under the name given in Question 1 (No further details are required).

I/We have previously held a minerals tenement in Victoria (within last 5 years), under another name (Attach details).

I/We have previously held a minerals tenement outside Victoria (within last 5 years) (Attach details of location and type of most recently held tenements and describe operation).

I/We have not previously held a minerals tenement within last 5 years (Attach details of your relevant mining/exploration experience).

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

Has failed to undertake rehabilitation required under the MRSDA and the Minister has taken action to rehabilitate the land under section 83 of the MRSDA;

Has had a licence cancelled under the MRSDA;

Has been convicted of an offence against the MRSDA;

Has been convicted of an offence involving fraud or dishonesty; or

Is an insolvent under administration.

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):

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

Other

(specify):

Secondary minerals to be explored:   

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

Other

(specify):

Question 11: Work program details

The program of work should include:

The nature of the program proposed (a preliminary assessment of literature, geotechnical exercises, drilling of delineated targets, etc); A description of the nature of the targets that the program seeks to delineate; As far as is practicable, an indication of the location and focus of the proposed exercises with location maps; A description of the geological rationale behind the proposed program; and An estimated schedule for the exploration program.

Indicate the nature of targeted mineralisation (if known):

Alluvial deposits Shallow lead Underground reef Bulk low grade deposit Deep lead Other (Specify):

Is the work program proposed also to be the work plan? Yes No

Note: Low impact exploration does not require a work plan. However, where a work plan is required (i.e. intrusive exploration works), the work plan must contain the details specified in Schedule 12 of the MRDR.

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

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

31 March

30 June

30 September

31 December

Question 13: Licence term required

years

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

Application 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:	(Applicant, Director, Secretary or authorised person)
Signature:
Date:
2. Name:
Position:	(Applicant, Director, Secretary or authorised person)
Signature:
Date:

Attachments Checklist

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

Map according to the Map Grid Australia 1994 (MGA94) showing area covered by application

List of Directors and their Date of Birth details, of the applicant Company (if applicable)

Copy of Certificate of Registration of applicant Company (if applicable)

Evidence of authorisation from applicant for agent to act on their behalf (if applicable)

Work program details

Evidence of financial capability

Statement by non-employee advisors of agreement to act as advisors for this application (if applicable)

Application Fee

Other attachments (give details below):

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 DPI to assist in the performance of duties under the MRSDA.

You have the right of access to this information by contacting the Earth Resources Business Centre, Department of Primary Industries, 16th Floor, 1 Spring St, 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 BUSINESS CENTRE, 16TH FLOOR, 1 SPRING ST MELBOURNE VICTORIA 3000 (GPO BOX 4440, MELBOURNE VICTORIA 3001) PRIORITY IS ALLOCATED ACCORDING TO THE DAY THE APPLICATION IS RECEIVED BY THE BUSINESS CENTRE

Department of Environment and Primary Industries, Victoria, Australia
Customer Service Centre: Phone 136 186 | National Relay Service/TTY 133 677

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