Applicant details*
Full name of applicant:
Address for service:
Email address:
Full name and telephone number of general contact person for application:
Full name and telephone number of financial contact person for application:
Full name, telephone number, and email address of geotechnical contact person for application:
Type of applicant: Incorporated society/overseas company/partnership/charitable trust/registered company/local authority/industrial and provident society/Crown/other [state type]
Applicant's New Zealand Companies Office number (if applicable):†
*The personal information you must include in this form is needed to process your application under the Crown Minerals Act 1991. You have the right under the Privacy Act 1993 or the Official Information Act 1982 to access and request that this information be corrected.
†The unique number assigned to the company on its incorporation.
Permit details
Permit type to which application relates:
Permit number (if application for subsequent permit):
If this is a prospecting application, is a non-exclusive permit sought? Yes/No
Duration: (years) (months)
Area: (hectares/square kilometres)
Location: (region) Onshore: Yes/No
Application fee
Cash Credit card Cheque Direct debit Direct credit
Supporting information
Please send with your application the prescribed fee required under the Crown Minerals (Petroleum Fees) Regulations 2006 for an application of this type (or evidence of it having been paid) and any information that is required under the Crown Minerals (Petroleum) Regulations 2007 to accompany an application of this type.
Authorised signature‡
Authorised signature(s):
Date:
‡If made by 2 or more persons, this application must be signed in accordance with regulation 6 of the Crown Minerals (Petroleum) Regulations 2007.