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No. (Office Use Only)
Application for ministerial approval
of a coordination arrangement
MINES ABN 59 020 847 551
Petroleum and Gas (Production and Safety) Act 2004
Geothermal Energy Act 2010, Greenhouse Gas Storage Act 2009
Form MMOL-37 Version 1
You may make an application for ministerial approval of a coordination arrangement 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
form, attach a separate page.
. Where insufficient space anywhere on this
Question 1 – Permit and holder details
Permit number (eg. PL1)
Current expiry date:
Holder 1
Holder 2
Holder 3
Company
Name/surname:
Given name (if
individual):
ACN/ARBN
% Holding:
Question 2 – Coordination arrangement details
2.1 Is this coordination agreement to be included or form part of a coordination arrangement under the
Petroleum and Gas (Production and Safety) Act 2004?

Yes

No
Providing the overlapping authority details subject to the arrangement:
Overlapping Authority
Number
Mining Lease
Mining Claim
Mineral Development Licence
Exploration Permit Mineral/Coal
Greenhouse Gas Permit/Lease
Authority to prospect
Petroleum Lease
Geothermal Permit/Lease
OFFICE USE ONLY
Fees paid:
Payment Method:
Received at: ________________
Total $ _______
Cash
Received by:
DNRM
Credit Card
Penalty
EFTPOS
Receipt No.
______________
Cheque
Date:
Time:
/
/
AM/PM
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: ___________________________
Signed:___________________________ Date:
/
/
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Question 3 – Proposed parties details
Specify proposed person who are a party to the coordination arrangement:
Attachments required:
•
Original or a certified copy of the proposed coordination arrangement signed by all parties
•
o
The arrangement clearly identifies the safety responsibilities of each party to the arrangement for the
land the subject of the arrangement; and

o
The spatial relationship between the relevant authorities for the arrangement is appropriate

If the proposed arrangement is inconsistent with the work program or development plan for the relevant permit,
the application must be accompanied by the following document:
• a proposed later work program complying with the later work program requirements.
• a proposed later development plan complying with the later development plan requirements.


Question 4 – Obligations and declaration
WARNING: Giving false or misleading information is a serious offence.
•
•
•
•
I have read and understood the resource guides and resources legislation.
I understand my obligations as an applicant/holder for the permit.
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:
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Print name:
Signature:
Position:
Date:
Company:
Print name:
Signature:
Position:
Date:
Company:
Question 5 – Payment
Application
Coordination arrangement fee

OFFICE USE ONLY CHECKLIST Has coordination arrangement and other requirements been provided?
YES/NO/NA
Application fee has been lodged with application?
YES/NO/NA
Receiving officer
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 for approval of a coordination arrangement has / has
not provided all the information required by the legislation to be
assessed.
I recommend that the application should / should not be received.
Name: ___________________________
Signed:___________________________
Date:
/
/
Reasons for refused to receive:
_______________________________________________________
Departmental Officer
The application for approval of a coordination arrangement is received
and can be recorded on the register or refused to be received
under s842 of the P&G
_______________________________________________________
_______________________________________________________
Name: ________________________________________
Signed:___________________________
Date:
/
/
Disclaimer
The Queensland Government is collecting information provided on this form for the purpose of assessing the suitability of your application for
Ministerial approval of a coordination agreement and maintain the public searchable register under the Petroleum and Gas (Production and Safety)
Act 2004 (P&G), Geothermal Energy Act 2010 (GEA) and Greenhouse Gas Storage Act 2009 (GHG). This information is authorised by sections 188
and 340 of the GHG, sections 140 and 273 of the GEA and section 235 and 565 of the P&G. Some or all of this information may be provided to other
agencies of the Queensland Government for the issuing of an environmental authority, or through arrangements with other government agencies
authorised to make register searches, extracts or copies under section 342 of the GHG, section 275 of the GEA and 566 of the P&G, 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.
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