Change Of Address Of A Permit Holder Page 2
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1
2Part B – Address and contact details
2
I/we are applying to:
Change the authorised holder address OR
Change the address of other permit holders.
3
New address for permit holder
Name
Address
Suburb
State
Post code
Phone number
(AREA CODE
)
Email address
Part C – Declaration
4
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.
Print name:
Signature:
Position:
Date:
Company:
Print name:
Signature:
Position:
Date:
Company:
Note: To register for the MyMinesOnline system (this will enable you to conduct an increasing
number of transactions for your permits online) please complete the
registration form
which can be
accessed from our website.
Disclaimer
The Queensland Government is collecting information provided on this form for the purposes of assessing the suitability of your request to record
change of address and maintain the public searchable register under the Mineral Resources Act 1989 (MRA) Petroleum and Gas (Production and
Safety) Act 2004 (P&G), Petroleum Act 1923 (PET), Geothermal Energy Act 2010 (GEA) and Greenhouse Gas Storage Act 2009 (GHG). This
information is authorised by sections 387 and 388 of the MRA, 565 and 852 of the P&G, 80B and 129 of the PET, 340 and 421 of the GHG and 273 and
376 of the GEA. Some or all of this information may be provided to other agencies of the Queensland Government for the issuing of an environmental
authority, to make register searches, extracts or copies under section 387B of the MRA, 566A of the P&G, 80CA of the PET, 342 of the GHG and 275 of
the GEA, 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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