Form 14
MINING ACT 1971
SURRENDER (OR PARTIAL SURRENDER) OF LEASE
(Please use BLOCK LETTERS) I, (Full name or company name) of (Full address for correspondence or company registered address)
being the lessee under the Mining Act 1971 of the lands comprised in Lease No. situated at
do, subject to the consent of the Minister under the Mining Act 1971 – surrender the lease and the lands comprised in the lease, and all my rights and title under the lease surrender the portion of the lands comprised in the lease delineated in the attached plan, and all my rights and title under the lease to the extent of the surrender. (Tick whichever is applicable) Additional information: 1. Contact telephone number: 2. 3. Contact facsimile number (if available): If the applicant is a company: (1) A.C.N. No.: (2) Contact person: DATE: SIGNATURE: …………………………………… or COMPANY SEAL2: WITNESS1: …………………………………… …………………………………… (Director) …………………………………… (Director/Secretary)
1
The witness must be a Justice of the Peace, Officer of the Department, Member of the Police Force, Proclaimed Bank Manager or Commissioner for Taking Affidavits. 2 If the lessee is a company, the surrender must bear the company’s seal and be witnessed by appropriate officers. Consent is given to this surrender. …………………………………… (Minister or delegate under the Act)
LSD 14
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