Applicant details. To apply for an amendment to a permit you must be the current holder of the existing permit. Include Australian Company Number (ACN) if the proposed permit holder is a body corporate or other entity formed at law. Are you applying as an individual, a company or incorporated body? Enter details for one only. An individual Title Mr ☐ Mrs ☐ Ms ☐ Other: Name/s OR A body corporate or Silver Lake (Integra) Pty Ltd other entity formed at law (include ACN) 000000000 Applicant contact details If applying as a company or incorporated body, please also supply the registered business office address. DWER and DMIRS prefer to send all correspondence electronically via email. We request that you consent to receiving all correspondence relating to instruments and notices under Part V of the EP Act (“Part V documents”) electronically via email by indicating your consent in this section of the application form. Where ‘yes’ is selected, all correspondence from DWER or DMIRS (as applicable) will be sent to you via email, to the email address provided in this section. Where ‘no’ has been selected, Part V documents will be posted to you in hard copy to the postal/business address you have provided in this section. Other general correspondence may still be sent to you via email. Provide contact details for the above individual or body corporate. Contact person (and Xx Xxxxxx position, if applicable) Environment Manager Company name Silver Lake Resources Limited (if applicable) Postal / business PO Box 876; address South Perth WA 6951 Phone (fixed line): 63133800 Phone (mobile): 0000000000 Email address xxxxxxx@xxxxxxxxxxxxxxxxxxx.xxx.xx I consent to all written correspondence between myself (the applicant) and DWER/DMIRS (as applicable), regarding the premises which is the subject of this application, being exclusively via email, using the email address I have provided above. Yes No ☒ ☐ Contact details for enquiries If different from the applicant’s contact details, enter the contact details of a person with whom DWER or DMIRS should liaise with concerning this clearing application. Where contact details differ to those of the applicant, complete the below section: Contact person (and position, if applicable) Company name (if applicable) Postal / business address Phone (fixed line) Phone (mobile) Email address
Applicant details. An Agent could be one of the following: Architect, Engineer, Lessee, Developer, Prospective Purchaser, Building Practitioner, Urban Planner, and Agent for Contractor etc. (
Applicant details. Name of applicant: ABN (if applicable): Name of authorised person (if Applicant is an organisation): Address: Email: Mobile: Date: Signature of applicant:
Applicant details. Please read Notes 2 and 3 to ensure this page of the form is completed correctly a Company/organisation name b Title (e.g. Mr, Mrs, Miss, Ms) c First name d Last name e Contact address f Contact telephone number g Contact email address h Landlord registration number
Applicant details. The title of the research project is requested. The application should be in the name of the principal worker. Affiliation, position, address, phone and mail should be added. In addition, name surname and affiliation of all the field assistants should be listed. Furthermore, state if any locally-based fieldworker(s) or scientist(s) has been engaged in the research activity. If so, please provide the personal details. Be aware that it is essential that the licence must be carried at all times by those engaged in the work, as evidence that the work being carried out is legitimate.
Applicant details. Title: Mr, Mrs, Miss Dr, Rev, Other Surname / Name of Company First Name(s) ONLY FOR INDIVIDUALS Passport / Identity Number / Company Registration Number Postal Address Email Address Telephone Number PREFERENCE & ORDINARY SHARES APPLIED FOR Number of Preference Shares The minimum application is for 10 shares. Enter a figure only - not words. Maximum Amount to be Paid is US) (should the full number of Preference Shares applied for to be alloted) Enter figure only - not words. US$ ORDINARY SHARES APPLIED FOR Number of Ordinary Shares The minimum application is for 10 shares. Enter a figure only - not words. Maximum Amount to be Paid in US) (should the full number of Ordinary Shares applied for to be alloted) Enter figure only - not words. US$ APPLICANT BANK ACCOUNT DETAILS FOR PAYMENTS OF REFUNDS, DIVIDENDS AND ANY OTHER INCOME Bank Name Branch Code Branch Name SWIFT Code Account Number Custodian Name VFEX Account Number PLEASE SIGN AND DATE THIS FORM BELOW, WHEN YOU HAVE COMPLETED YOUR DETAILS. Signature(s): Date:
Applicant details. Please complete the information listed below: Entity name Legal form Registered office Attn Street/N° City/Town Post Code Country Trade Register Registration number Tel Fax E-mail 1 Contact ¨Person Position
Applicant details. Title: Mr Mrs Ms Dr Prof Xxxxxxx: First name/s: ID number: Date of birth: Gender: Male Female Race: Black African Black Coloured Black Indian White Nationality: Citizen status: D - Dual (SA plus other) O - Other PR - Permanent Resident SA - South Africa Home language: Disability status: None Hearing Impaired Disabled but unspecified Physical Sight Impaired Multiple Communication Impaired DECLARATION BY STUDENT RELATING TO APPLICATION FOR ADMISSION AND THE ENROLMENT CONTRACT I, the undersigned applicant, do hereby:
Applicant details. (Refers to the detail of the person requesting the change.) Name: Surname: Designation / Rank: Date: Organisation: Email: Tel/Cell: Please supply the contact detail of the person to whom the processed application must be returned. dd/mm/yyyy Details of Data Request: (please append any additional information where necessary) Type of Data Requested : (please tick appropriate option) Aggregated data Non-identified individualised data Identified individualised data Please provide a short description of the data requested. Please attach a list/attach a list of the variables required. Do you have a National Health Research Database ref no.? Yes No Number: Time period the data should cover: Start date: dd/mm/yyyy End date: dd/mm/ yyyy Frequency of Access: (please tick appropriate option) Once-off Periodically If periodically, please specify time frames for access: Is the data to be used for research purposes? Yes No Please provide a brief motivation for this request, highlighting the purpose for which the data will be used Study not funded/funded by: Do you have a security protocol for handling the data (attach detail if necessary)? Yes No
Applicant details. (Refers to the detail of the person requesting the change.) Name: Surname: Designation / Rank: Date: dd/mm/yyyy Organisation: Email: Tel/Cell: Please supply the contact detail of the person to whom the processed application must be returned.
