NEW SOUTH WALES GOVERNMENT by 140RIE7X

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									                                                                            ABN 72 189 919 072




                                    MINING ACT 1992
                                      Section 163C

                       EXTENSION OR EXEMPTION
                     FROM REPORTING APPLICATION
                                        FORM ER01
This form is to be used for extensions to, or exemptions from, reporting on individual
authorities or multiple authorities where group reporting is sought..
1.      Authority Number(s) (eg Mining Lease No. 123, Act 1992 or Exploration
        Licence No. 5555, Act 1992)




2.      Name of authority holder/s in full and ACN/s (for company/s)




3.      Address for correspondence and Contact Name, Telephone, Fax
        Number and Email: All correspondence will be forwarded to this address
        until the Titles Program is notified of any change. Any personal contact will
        also be with the person named.

        Address Details:



        Telephone Contact:                                 Fax Contact:

        Contact Name:                                      Email contact:


4.      Period for which extension is sought: _ Months to __/__/__

                OR

        Exemption sought: Yes/No

5.      Grounds of application: (including reason for non-compliance)




                                               Extension or Exemption from Reporting Requirement   1
                                                                                    ABN 72 189 919 072




6.        Accompanying this application are:
          (a)  Documentation to support the grounds for the extension or
               exemption from reporting requirements.

7.        I/WE CERTIFY THAT ALL OF THE PARTICULARS REQUIRED TO
          ACCOMPANY THE APPLICATION HAVE BEEN SUPPLIED.


.............………....  ......……….............             .......………...........
(Signature/s of Holder/s)


Application must be lodged with the Director-General, Department of Industry and
Investment. The application should be addressed to the Manager, Minerals Titles and
Lightning Ridge or the Manager, Coal and Petroleum Titles, as required.

The application may be lodged at the Mineral Resources Branch at either 516 High Street,
Maitland NSW 2320 (PO Box 344, Hunter Region Mail Centre NSW 2310), or 161 Kite
Street, Orange NSW 2800 (Locked Bag 21, Orange NSW 2800).


FOR OFFICE USE

Application Received: ........................ am/pm ................................. / ....... / 20


Signed:..............................   for Director-General.


PRIVACY STATEMENT

This information is collected by Department of Industry & Investment for the purposes of assessing an
application for an authorisation, or associated with an authorisation as required by the Mining Act 1992
or Mining Regulation 2010.

This information may also be used by the Department to confirm applicant details in the event that
subsequent applications are made, and may also be used to establish and maintain databases to
assist the Department with its work generally.

Except for purposes required by law, the information will not be accessed by any third parties in a way
that would identify the person without the consent of that person.

You may apply to the Department to access and correct any information the Department holds if that
information is inaccurate, incomplete, not relevant or out of date.




2                                                     Extension or Exemption from Reporting Requirement

								
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