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APPLICATIONform
Petroleum retention lease
In accordance with Section 141 or 147 of the Offshore Petroleum and Greenhouse Gas Storage Act 2006.
Title number
(Exploration permit or production licence number)
Application under Section 141—holder of an existing petroleum exploration permit
Date of location declared
Longer application period granted
Application under Section 147—holder of an existing petroleum production licence
Licence grant date OR
Last day of petroleum recovery operations
Application details
Applicant(s)
ASIC ACN/ARBN No:
(Company or Individual Name(s))
(if applicable)
Interest (%)
(Must total 100%)
%
%
%
%
%
%
Location / field information
Location / field name
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
www.nopta.gov.au
APPLICATIONform
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
Block information
Mapsheet
(Note: if there is more than one mapsheet please provide a separate attached listing for each
Mapsheet block number(s))
Block number(s)
(Note: if there is insufficient space allowed please attach additional pages)
Payment of application fee
The correct application fee must accompany the application
(pursuant to section 256 of the Act and Schedule 6 of the Offshore Petroleum and Greenhouse Gas Storage (Resource Management
and Administration) Regulations 2011)
Specify payment method
Applicant contact details
Company Name
Company Address
Postal Address (if not the same as above)
Contact Name
Position Held
Phone
Fax
Email
www.nopta.gov.au
APPLICATIONform
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
Executed in accordance with Section 141 or 147 of the Offshore Petroleum and Greenhouse Gas Storage
Act 2006.
Where the applicant is an individual
Executed by
Executed by
Signature
Signature
Date
Date
Full name (please print)
Full name (please print)
And/or
Where the applicant(s) are a company
Executed by
Executed by
Company Name
Company Name
Signature
Signature
Date
Date
Full name (please print)
Full name (please print)
Position
Position
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
www.nopta.gov.au
APPLICATIONform
Executed by
Executed by
Company Name
Company Name
Signature
Signature
Date
Date
Full name (please print)
Full name (please print)
Position
Position
The following details must be attached to this application
Checklist
1
Description
Details of the applicant’s proposals for work and expenditure in relation to:
 the area comprised in the block or blocks specified in the application, or
 in relation to the unused area.
Attached
☐
2
Details of the current commercial viability of the recovery of petroleum:
 from that area, or
 from the unused area.
☐
3
Details of the possible future commercial viability of the recovery of petroleum:
 from that area, or
 from the unused area.
☐
4
A statement of any other matters that the applicant wishes considered.
☐
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
www.nopta.gov.au
APPLICATIONform
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
Application fee
Cheques
Please make cheques out to ‘NOPTA—Commonwealth of Australia’.
Please write your full company name, ABN and ‘application fee for Retention Lease‘ on the back of the
cheque, and include with your application.
Direct deposit
Account information
BSB Number
Account Number
Reference
Details
092–009
119–585
Please insert the first 3 letters of your company name and ‘RL APP‘ in the
reference field to ensure your payment may be processed.
Please also include a note with your application if you have paid your fee by direct deposit.
Submission details
Office
Perth
Melbourne
By post
Titles Manager
NOPTA
Resources Division
Department of Industry
GPO Box 7871
Perth WA 6850
Titles Manager
NOPTA
Resources Division
Department of Industry
GPO Box 4634
Melbourne VIC 3001
By email
[email protected]
Phone
(08) 6424 5317
Office Hours
09:00–17:00
Mon-Fri
[email protected]
(03) 8199 0300
09:00–17:00
Mon-Fri
Notes
Two (2) bound paper copies and three (3) electronic copies (on CD or USB in text search supported format)
of the application must be submitted to NOPTA.
In making an application please refer to the Offshore Petroleum and Greenhouse Gas Storage Act 2006.
The Guidelines ‘Grant and Administration of a Retention Lease’ and ‘Declaration of a Location’ contain
further details of what should be included in an application for a retention lease.
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
www.nopta.gov.au