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Retention Licence Application Form

Mineral Resources (Sustainable Development) Act 1990 (MRSDA)

ALL information required by Schedule 3B 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 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)

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:

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):

Please select one:

Applicant Employee Agent

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.

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).

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 5a: Does the application area lie within an Exploration Licence (EL) or a Prospecting Licence (PL) either granted or applied for?

No
Yes

Give licence number

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/PL
or
A letter of consent from the EL/PL holder/applicant is attached

Question 5b: Does the application area lie within a Mining Licence (MIN) either granted or applied for?

No
Yes

Give licence number

A retention licence can be applied for on land that is covered by a mining licence or mining licence application, but only for the period from 1 February 2012 to 31 January 2013.

If you have ticked YES to the above question, indicate one of the following:

I/We are the owner(s)/applicants(s) of the MIN
or
A letter of consent from the MIN holder/applicant is attached

Question 6: Estimated expenditure for the first 2 years and estimated expenditure for the life of the licence

Year 1

Year 2

Estimated Total Expenditure

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	$
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

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 & 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

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 10: Indicate your experience in project evaluation and development activities

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

I/We have previously developed a mining operation in Victoria (within last 5 years) under another name (Attach details).

I/We have previously developed a mining operation 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 developed a mining operation within last 5 years (If this is the case, please attach details of your knowledge of mining project evaluation and development and your ability to acquire relevant experience in project evaluation/development activities).

Question 11: 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 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:

Types of minerals identified;

Location, depth, quantity and extent of the minerals;

Method by which that extent has been determined;

Analytic results obtained from samples of those minerals; and

An analysis of whether exploration results indicate that there is reasonable prospect that mining of the described mineral resource will be economically viable.

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

The mineral resource is not currently economically viable to mine; and

The mineral resource could become economically viable to mine in the future.

If the retention licence application is being applied for on land covered by a mining licence or covered by a mining licence application (as per Question 5b), please indicate whether:

The mineralisation report is attached

The mineralisation report will be provided within 12 months of application date

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:

Contact details of the competent person who prepared the report;

Relevant professional organisation membership/s of the competent person who prepared the report;

Relevant experience of the competent person who prepared the report.

Question 14: Details of the program of work

Attach a program of work that details the:

Nature of the intensive exploration program proposed (in-fill drilling, bulk sampling, etc) and an indication of the location and focus of the proposed exploration with location maps;

Mineral resource assessment and technical and/or economic studies related to the development of the mineral resource;

A time schedule for the work program including key milestones and proposed expenditure against each milestone;

Demonstration that the scale and outline of the proposed work and level of expenditure is commensurate with the size of the mineral resource.

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:

JORC inferred mineral resource; or

JORC indicated mineral resource; or

Alternative mineral resource standard as provided in the Ministerial guidelines.

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

31 March

30 June

30 September

31 December

Question 18: Application Fee

Application for Retention 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) labeled 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)

Mineralisation Report

Description of Mineral Resource (as per Ministerial guidelines)

Work program details

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

Written consent from MIN/EL/PL holder/applicant over application area (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 Street, 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 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 Business Centre 16th Floor, 1 Spring St Melbourne VIC 3000 (GPO Box 4440, Melbourne VIC 3001) Priority is allocated according to the day the application is received by the Earth Resources Business Centre.

Office Use Only

Date Received:

Delivered: In person / By post

Checked by:

Retention Licence no:

District: