form –4: application for mining license

Endereço : Andar Térreo Ala Leste do Palácio do Governo, Edifício nº 1, Avenida Marginal
Dili, Timor-Leste, PO Box 113, Telephone: +670 3 324 098 / 3317216 / 3317215 / 3312735
FORM –4: APPLICATION FOR MINING LICENSE
Attention to;
Manager of Mineral Exploration and Exploitation
Autoridade Nacional do Petróleo e Minerais, Timor-Leste
In accordance with the requirements in the Ministerial Diploma No........Article...........issued by
the Ministry of Petroleum and Mineral Resources of Timor-Leste, the undersigned hereby
applies for a Mining license to carry out mining activity.
The area applied for is in public and/or private land, river, creek or other public waters (underline
applicable
term),
located
___________________,
in
the
Posto
of
Aldeia
of
__________________,
_____________________,
Suco
municipality
of
of
__________________________.
Following are supporting information for this application (ticked below boxes and attached
supporting documents to this application where applicable):
Autoridade Nacional do Petróleo e Minerais
Endereço : Andar Térreo Ala Leste do Palácio do Governo, Edifício nº 1, Avenida Marginal
Dili, Timor-Leste, PO Box 113, Telephone: +670 3 324 098 / 3317216 / 3317215 / 3312735
Particulars of applicant
Particulars of organisation (Company/association)
Particulars of finance
Particulars of technical competence and experience
Particulars of other requirements
Declaration
(Signature)
__________________
(Applicant)
Autoridade Nacional do Petróleo e Minerais
Endereço : Andar Térreo Ala Leste do Palácio do Governo, Edifício nº 1, Avenida Marginal
Dili, Timor-Leste, PO Box 113, Telephone: +670 3 324 098 / 3317216 / 3317215 / 3312735
INFORMATION TO BE PROVIDED FOR APPLICATION OF MINING
LICENSE
CATEGOTRIES
CLASSIFICATION
CONSTRUCTION
.......
MATERIALS
ARTISANAL
.......
PROCESS MATERIALS
.......
MEDIUM SCALE
.......
DIMENSION AND
.......
ORNAMENTAL STONES
LARGE SCALE
.......
PARTICULARS OF APPLICANT
Name of applicant:
Type of Identification
Document :
Taxpayer Number ( TIN ) :
Autoridade Nacional do Petróleo e Minerais
Identification Document No. :
Endereço : Andar Térreo Ala Leste do Palácio do Governo, Edifício nº 1, Avenida Marginal
Dili, Timor-Leste, PO Box 113, Telephone: +670 3 324 098 / 3317216 / 3317215 / 3312735
Address :
Municipio :
Posto
Suco
Aldeia
Telephone :
Fax :
Email
PARTICULARS OF ORGANISATION (COMPANY/ASSOCIATION)
Name of Company:
Address:
Business registration certificate and company statute (with documentary evidence)
Tax Identification Number (TIN):
Share Capital:
Name and Nationality of Company Chief Executive :
PARTICULARS OF FINANCIAL STANDING
Details of financial availability for intended operations (with documentary evidence)
Insurance coverage for the proposed prospecting activity (with documentary evidence)
PARTICULARS OF TECHNICAL COMPETENCE AND EXPERIENCE
Autoridade Nacional do Petróleo e Minerais
Endereço : Andar Térreo Ala Leste do Palácio do Governo, Edifício nº 1, Avenida Marginal
Dili, Timor-Leste, PO Box 113, Telephone: +670 3 324 098 / 3317216 / 3317215 / 3312735
Details relevant to Mining/mining experience (with supporting documentary evidence)
Details of previous mining rights held
PARTICULARS OF OTHER REQUIREMENTS
-
A. Mining proposal (to be separately attached to this form) containing at least the
following;
Executive Summary
Objective of Mining
Geology and Exploration result indicating the regional geology, geology of the area,
types of minerals in the area, resource and reserve.
Development plan covering operations site layout , construction and installations,
requirements and specification of equipments used for mining, material handling,
overburden and interburden, drilling/blasting, processing, transportation and marketing
of extracted materials, estimate investments and cost of production, etc.
Mining plan covering mining method, Production forecast, etc
Health and Safety plan
Organisation and Manpower
Mine Closure Plan
Statement of commitment to contribute to Mine Closure Fund
-
B. Submit the following documents
Business Registration Certificate
Certificate confirming non-existence of tax
Bank Statement of capital fund
Company’s by-law.
Proof of insurance covering the operation.
CV’s of technical staffs and Declaration Sign by head of technician in charge
Relevant Environmental License
National Directorate of Land and Property clearance
Proof of payment of application fee
-
DECLARATION
Autoridade Nacional do Petróleo e Minerais
Endereço : Andar Térreo Ala Leste do Palácio do Governo, Edifício nº 1, Avenida Marginal
Dili, Timor-Leste, PO Box 113, Telephone: +670 3 324 098 / 3317216 / 3317215 / 3312735
The applicant, .........................................................................................hereby;
1.
Declares that the information made in this application or made later in support
hereof are true to the best of the applicant’s knowledge. The applicant consent that
any falsehood of information in this application may result in rejection to grant
license.
2.
Agrees that all information to be collected from the proposed activity and their
associated results from subsequent analysis will be made available to the ANPM in
any form or shape at no cost.
Signature of the applicant’s representative
To be completed by the ANPM
Fees to be paid :
[signature]
License Fee USD ………………........
……………………………..
Mining Fee USD ………………........
[Name]
Place :……………………………
Date……../……../………
[signature]
……………………………………........…
[name]
[Date]
Autoridade Nacional do Petróleo e Minerais
Endereço : Andar Térreo Ala Leste do Palácio do Governo, Edifício nº 1, Avenida Marginal
Dili, Timor-Leste, PO Box 113, Telephone: +670 3 324 098 / 3317216 / 3317215 / 3312735
INSTRUCTION
1. This form shall be completed by the applicant and submit to the ANPM office, in both
soft and hard copy.
2. All relevant information in the field required must be marked and given accordingly.
3. Application not accompanied with all the required documents may not be accepted.
Autoridade Nacional do Petróleo e Minerais