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Prospecting Licence Application Form

Mineral Resources (Sustainable Development) Act 1990 (MRSDA)

ALL information required by Schedule 3A of the Mineral Resources Development Regulations 2002 must be provided or the application is invalid. Section 15 of the MRSDA also sets out additional requirements for Prospecting Licences.

Question 1: Name and Address of applicant(s)

1. Mr/Mrs/Ms:

Surname or Company name

Given name

ABN (if applicable):

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. Mr/Mrs/Ms:

Surname or Company name

Given name

ABN (if applicable):

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 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

1:25,000 Map Names(s):

Area hectares

A map of scale 1:25,000 or larger must be attached clearly showing the boundaries of private land and Crown land. You must also attach a note describing the relationship of the application area to land title boundaries where applicable.

Does the application area include privately-owned agricultural land which is not owned by the applicant(s)?

No Yes (If YES you must attach a map clearly showing the extent of land used as agricultural land. (Map scale 1:25,000 or larger)

Question 4: Names and addresses of owners and occupiers of the land

Name:

Owner Occupier

Parish(es)

Crown Allotment(s)

Number and street name:

City

State

Postcode

Name:

Owner Occupier

Parish(es)

Crown Allotment(s)

Number and street name:

City

State

Postcode

(If more than two owners/occupiers, please attach list).

Question 5: 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; or

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 6: Does the application area lie within an Exploration Licence (EL) or Retention Licence (RL) either granted or applied for?

Give licence number

No Yes

If YES please tick the appropriate box below:
(The application is invalid if you cannot tick one of these questions below)

I/We are the owner(s)/applicants(s) of the EL/RL
or
A letter of consent from the EL/RL holder/applicant is attached
or
Evidence of request for EL holder consent and copy of refusal of EL holder consent and 25A waiver application attached.

Note: A section 25A waiver application can only be made if the EL was registered more than 2 years ago and the written consent of the holder of this EL to the granting of the PL has been requested and refused and a request for a waiver of the need for consent is attached to the application. The Section 25A Waiver Request is at the back of this application form.

Question 7: Licence term required

years

A prospecting licence may be granted for a period not exceeding five years.

Question 9: Estimated expenditure for first 2 years and for the term of the licence

Year 1

Year 2

Term of the licence

Question 10: 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 or Company (without audited financial report):
Assets:

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 & 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 11: 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 12: Indicate your experience in mining and exploration 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 knowledge and relevant mining/exploration experience).

Question 13: 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;

Is 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 14: Work program details

The program of work should include:

A sketch map of the location of the proposed works in relation to the boundaries of the land included in the application; and

A brief description of the proposed type of works including, if required, the type of ore treatment.

Proposed Type of Operation:

Hard Rock Open Cut	Doze and Detect	Bulk sampling/surface/ trenching/exploration
Hard Rock Underground	Alluvial	Shallow excavation (gypsum, kaolin)

Other (specify):

Type of Treatment:

No Treatment	CIL/CIP	Vat Leach
Gravity	Heap Leach	Mercury

Other (specify):

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

Question 15: Application Fee

Application for Prospecting Licence $

Note: The application must be accompanied by the prescribed fee. Refer http://www.dpi.vic.gov.au/about-us/legislation/fees/earth-resources

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 Geocentric Datum of Australia 1994 (GDA94) labelled with MGA (Map Grid of Australia) coordinates 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)

Written consent from EL/RL holder/applicant over application area (if applicable).

Application for Section 25A EL holder consent waiver (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 Investment 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:
Prospecting 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

APPLICATION FOR SECTION 25A EXPLORATION LICENCE HOLDER CONSENT WAIVER

Note: ONLY APPLICABLE IF APPLICATION IS WITHIN AN EXPLORATION LICENCE THAT HAS BEEN REGISTERED FOR MORE THAN 2 YEARS (SEE QUESTION 6).

Manager, Earth Resources Tenements
Department of Primary Industries
Earth Resources Regulation
Level 16, 1 Spring Street
MELBOURNE VIC 3000

ATTENTION: EARTH RESOURCES BUSINESS CENTRE

I/We have applied for a prospecting licence for hectares

The land is covered by Exploration Licence Number

Exploration Licence was first registered on

I/We are unable to obtain the written consent of the holder of the Exploration Licence (evidence attached).

Signed:
Print Name:
Date:

For office use only

That the application is for a prospecting licence; and
That the covering exploration licence has been registered for two years or more; and
That granting of this prospecting licence would not cause the total number of prospecting licences granted by virtue of Section 25A (or mining licences granted by virtue of Section 25A before 1 February 2012) within this exploration licence to be more than one tenth the number of graticules of the exploration licence; and
That there is no other prospecting licence granted by virtue of Section 25A (or mining licence granted by virtue of Section 25A before 1 February 2012) within this exploration licence that is one kilometre or less from this application (from closest point).

Signed: ......................................................., GIS Officer

Name: ..........................................................

To the Mining Warden

I refer this prospecting licence application to you for a recommendation as to whether I should grant the waiver. Please provide your recommendation within 30 days.

The Prospecting Licence Application and Exploration Licence Tenement Reports are attached.

Manager Earth Resources Tenements
Earth Resources Regulation Branch
Delegate of the Minister for Energy and Resources

Date:

Print and Send Form

Department of Primary Industries

earth resources

Prospecting Licence Application Form

Question 11: Expertise of person(s), including the applicant, undertaking the exploration and/or mining program

Question 12: Indicate your experience in mining and exploration activities

Question 13: Indicate with a tick whether any of the following apply to the applicant or associate

Question 14: Work program details

Proposed Type of Operation:

Type of Treatment:

Question 15: Application Fee

Applicant's Declaration

Attachments Checklist

Privacy Statement