Application to conduct drilling and other activities on land not included in surface area No. (Office Use Only) MINES ABN 59 020 847 551 Section 237 Mineral Resources Act 1989 Form MMOL-29 Version 1 You may make an application to conduct drilling and other activities on your permit area electronically using the MyMinesOnline system. Alternatively you may complete the original of this application and submitting the application, any attachments and the prescribed fee at a Mines lodgement office. Note: A document containing information that is false or misleading may attract a maximum penalty of 200 penalty units. Please use a pen, and write neatly using BLOCK LETTERS Cross where applicable Question 1 – Permit and holder details Permit number (eg ML01234): Current expiry date: Detail the current holder(s) Holder 1 Holder 2 Holder 3 Company Name/surname: Given name (if individual): ACN/ARBN % Holding: Question 2 – Activities to be carried out (if additional space is required, attach a separate piece of paper) Description of activity to be carried out Length of activities (month(s)/years) OFFICE USE ONLY Fees paid: Payment Method: Received at: ________________ Total $ _______ Cash Received by: DNRM Credit Card Receipt No. EFTPOS Receiving officer I confirm that: • the details on application form have been checked; • all attachments have been submitted; • correct application fees have been submitted for the relevant application type Name: ___________________________ ______________ Cheque Signed:___________________________ Date: Date: Time: / / AM/PM / / Question 3 - Details of permit area Land parcel details 3.1 Provide property details for all land parcels not surface area covered by this application (add a separate page if insufficient space). Lot Plan Tenure Land Parcel name Current usage Eg. 1 RP123123 FH Smith road Grazing Proposed usage Mining or Access Landowner name Landowner address J Smith 123 Brisbane Rd, Brisbane Describe the area over which the activities are to be carried out on the land. 3.2 Which datum have you used:  GDA 94 (lat, long)  MGA94 (easting, northing, zone) 3.3 Provide coordinates for datum post: *coordinates must be in latitude and longitude on GDA 94 datum or MGA94 easting, northing, zone 3.4 Area description (include external boundary description) by providing details below or provide an electronic shape file using the Shape file templates available on our website with the application form. Refer to Shape file guide for more information. Latitude or Easting Longitude or Northing Zone Attachments required: • Map of permit identifying surface area subject to this application Question 4 – Consent and agreement details 4.1 Has the owner of the land provided written consent to the activities to be carried out?  Yes  No 4.2 Is an agreement for compensation in place?  Yes  No If yes - Attachments required: • Consent from the owner  • Compensation agreement  Question 5 – Obligations and declaration WARNING: Giving false or misleading information is a serious offence. • I have read and understood the relevant guides and resources legislation. • I understand my obligations as an applicant/holder for a resource authority. • I have truthfully declared all relevant details requested of me in this application. • If any part of this form has been completed with the assistance of another person, I declare that the information as set down is true and correct and has been included with my full knowledge, consent and understanding. Note: if this form is being signed by a person other than the current registered holder, a letter of authority or power of attorney documents must be provided with this application. Print name: Signature: Position: Date: Company: Print name: Signature: Position: Date: Company: Print name: Signature: Position: Date: Company: Print name: Signature: Position: Date: Company: Question 6 – Payment Application fee Conduct drilling fee  Page | 4 OFFICE USE ONLY CHECKLIST - YES/NO/NA Has consent been provided if holder has obtained consent? YES/NO/NA Has compensation agreement been provided if holder has obtained agreement? YES/NO/NA Has a shape or CSV file been provided to describe area being drilled? YES/NO/NA Has maps, graphical presentations been provided? YES/NO/NA Application fee has been lodged with application? Receiving officer I recommend that the application should / should not be received. I confirm that: • • • • the details on this form have been checked the checklist above are complete attachments required are correct correct fees have been submitted. The application to conduct drilling on a permit has / has not provided all the information required by the legislation to be assessed. Name: ___________________________ Signed:___________________________ Date: / / Reasons for refused to receive: Departmental Officer _______________________________________________________ _______________________________________________________ The application to conduct drilling on a permit is received and can be recorded on the register or refused to be received under s386Pof the MRA. _______________________________________________________ Name: ________________________________________ Signed:___________________________ Date: / / Disclaimer The Queensland Government is collecting information provided on and with this form to assess the suitability of the application to conduct drilling on a permit under the Mineral Resources Act 1989 (the Act). This information is authorised by sections 237, 387 of the Act. Some or all of this information may be provided to other agencies of the Queensland Government for issuing an environmental authority, to make register searches, extracts or copies under section 387B of the Act or to make other approvals as required under the Act. Your personal information will not otherwise be disclosed to any other third party without your consent, unless authorised or required by law. Page | 5