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Change of address
Section 388 Mineral Resources Act 1989, section 852 Petroleum and Gas (Production and Safety) Act 2004,
section 129 Petroleum Act 1923, section 376 Geothermal Energy Act 2010 and
section 421 Greenhouse Gas Storage Act 2009
Form MMOL-02 Version 4.1
Please use a pen, and write neatly using BLOCK LETTERS. Cross where applicable
You may complete the original of this application and submit the application, any attachments and the prescribed fee at a Mines
Lodgement Office.
Part A – Permit details
Permit type Tick Number(s)
Mineral Resources Act 1989:
o Exploration permit mineral
o
Exploration permit specified minerals
o
Exploration permit coal
o
Mineral development licence
o
Mining claim
o
Mining lease
Petroleum and Gas (Production and Safety) Act
2004 and Petroleum Act 1923:
o Authority to prospect
o
Petroleum lease
o
Petroleum survey licence
o
Petroleum pipeline licence
o
Petroleum facility licence
Geothermal Energy Act 2010:
o Exploration permit geothermal
o
Geothermal lease
Greenhouse Gas Storage Act 2009:
o Exploration permit greenhouse gas
o
Greenhouse gas injection and storage lease
OFFICE USE ONLY
Receiving officer
I confirm that:
• the details on application form have been
checked;
• all attachments have been submitted;
• correct application fees have been submitted.
Name: ___________________________
Signed:_________________________ Date: / /
Application entered onto
MyMinesOnline Y N
Name: ___________________________
Signed:___________________________
Date: / /
Received at: ________________
Received by: ________________
Date: / /
New MyMinesOnline user (Q7) copy of
application provided to STARS Y N
Time: AM/PM
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Mines ABN 59 020 847 551
Instructions
Part A: Permit details - Use this section to detail what permit details you want the changes to apply to.
Part B: Address and contact details - In this section, you can update a permit holder’s address; the address for a current
authorised holder representative (AHR = an individual who has the authority to liaise with the department on behalf of the
holders). You might know this as the address for service of correspondence.
Part C: New AHR - Nominate a new AHR (you will need to attach a letter of authority from the permit holders to do this).
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Part B– Address and contact details
I/we are applying to:
Change the authorised holder address
OR
Change the address of other permit holders.
OR
Change Authorised holder representative address (MyMinesOnline registered user)
New address for permit holder or authorised holder representative
Name
Address
Suburb
State
Post code
Phone number (AREA CODE )
Email address
Part C - Assign Authorised holder representative (this will be the primary contact person for the
permit(s))
I/we are applying to:
Nominate an authorised holder representative for the permits listed.
OR
Change to a new authorised holder representative for the permits listed.
Provide details for the authorised person to act as contact for the permits listed in Part A
Name
Address
Suburb
State
Post code
Phone number (AREA CODE )
Email address
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3
4
5
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Attachments required for Part B or Part C:
• Letter of authority from holders for authorised holder representative to act on behalf of holders (This is
not required if you are a sole holder representing yourself)
Part D – Declaration
WARNING: Giving false or misleading information is a serious offence.
• I/we understand my obligations as a holder of a resources permit.
• I/we 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/we declare that the
information as set down is true and correct and has been included with my full knowledge, consent and
understanding.
Signature 1:
Print name:
Position:
Signature 2:
Print name:
Position:
(if additional signatures, attach a separate piece of paper)
Note: To register for the MyMinesOnline system (this will enable you to conduct an increasing
number of transactions for your permits online) please contact the MyMinesOnline help desk on
[email protected] or 07 3199 8133.
Disclaimer
The Queensland Government is collecting information provided on this form for the purposes of assessing the suitability of your request and maintain
the public searchable register under the Mineral and Energy Resources (Common Provisions) Act 2014 (MERCP). This information is authorised by
section 197 of the MERCP. 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 or to make other approvals as required under the relevant Act. Some of this
information may be provided to Queensland Treasury, the Scheme Manager under the Mineral and Energy Resources (Financial Provisioning) Act 2018
(MERFP Act), or any advisors to the Scheme Manager to enable the Scheme Manager to carry out the Scheme Manager’s functions under the MERFP
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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