REGION

NAME OF APPLICANT

POSTAL ADDRESS

TELEPHONE NUMBER

FAXCIMILE

E-MAIL ADDRESS

Use of the surface of land other than in terms of a town-planning scheme approved in terms of section 53 of the Act.

Use of the surface of land other than for farming or uses incidental to farming.

Other non-agricultural land uses.

INFORMATION SUBMITTED

Mark with an X where applicable

YES

NO

Signed copy of a resolution by the applicant, authorising the person whose name and identification number is stated in paragraph 5 below to submit the application electronically on the applicants behalf.

Background information document

Plan of the area under application

Copy of the applicable title deed

Report on meaningful consultation with interested and affected persons in the mining industry

Report on meaningful consultation with the Council for Geoscience regarding both the mineral potential of the land concerned, and the possible presence of dolomitic formations thereon.

Electronic folder of copies of comments and concerns raised by parties with interests in prospecting, mining, exploration or production in the area and surrounding area.

Geological map of the area applied for

MINING AND PROSPECTING, PRODUCTION AND EXPLORATION INTERESTS AND GEOLOGICAL ISSUES

Mark with an X where applicable

YES

NO

Have the holders of prospecting, mining, exploration or production rights within a 2 kilometer radius of the application area been identified?

Have the holders of the aforesaid rights been meaningfully consulted?

Is the land concerned underlain by dolomitic formations?

Have any prospecting, mining, exploration or production right holders objected to the proposed land development on the basis of its incompatibility with their interests?

PROSPECTING OR EXPLORATION INTERESTS

Mark with an X where applicable

YES

NO

N/A

Are prospecting or exploration rights held over the land concerned or within 2 kilometers thereof?

Are there applications for prospecting or exploration rights within 2 kilometers of the land concerned?

Have the interested and affected persons identified above been meaningfully consulted?

Have the interested and affected persons been requested to specifically comment on the possibility that future occupiers of the proposed development may object to their prospecting, exploration or future mining or production activities?

Have the interested parties identified been requested to indicate how their current operations, including their environmental management obligations, will be affected by the proposed land development?

Have the aforesaid interested and affected persons been requested to indicate how potential future mining or production operations will be impacted on by the proposed land development?

Which minerals are being prospected for or explored on the land concerned?

Which minerals are being prospected for or explored within 2 Kilometers of the area applied for?

DESCRIBE BELOW HOW THE PROPOSED LAND USE WILL BE AFFECTED BY CURRENT PROSPECTING OR EXPLORATION OPERATIONS

DESCRIBE BELOW HOW THE PROPOSED LAND USE WILL BE AFFECTED BY POTENTIAL FUTURE MINING OR PRODUCTION ON THE LAND AND SURROUNDING AREA

PROVIDE A SUMMARY BELOW OF HOW HOLDERS OF PROSPECTING RIGHTS OR EXPLORATION RIGHTS IN THE AREA HAVE DESCRIBED THE MANNER IN WHICH THEIR CURRENT OR FUTURE INTERESTS IN THE AREA WILL BE IMPACTED UPON BY THE PROPOSED DEVELOPMENT, INCLUDING ANY IMPEDIMENTS TO PROSPECTING, EXPLORATION, PRODUCTION OR MINING THAT ARE FORSEEN, IMPACTS ON THEIR ENVIRONMENTAL OBLIGATIONS, AND THE POTENTIAL FOR OBJECTIONS TO THEIR ACTIVITIES BY FUTURE OCCUPIERS OF THE PROPOSED DEVELOPMENT.

MINING INTERESTS

Mark with an X where applicable

YES

NO

N/A

Are mining rights or production rights held over the land concerned or within 2 kilometers thereof?

Are there prospecting or exploration rights or applications for mining or production rights within 2 kilometers of the land concerned?

Have the interested and affected persons identified above been meaningfully consulted?

Have the interested parties identified above indicated how their current operations will be affected by the proposed land development?

Have the aforesaid interested and affected persons indicated how potential future mining or production operations will be impacted on by the proposed land development?

Which minerals are being mined on the land concerned?

Which minerals are being mined within 2 Kilometers of the area applied for?

State whether the mining or production on the land or within 2 kilometers of the proposed land development is opencast or underground in nature.

State the depth below surface that mining or production is or will take place as informed by the interested and affected persons identified above.

DESCRIBE BELOW HOW THE PROPOSED LAND USE WILL BE AFFECTED BY CURRENT MINING OR PRODUCTION OPERATIONS

DESCRIBE BELOW HOW THE PROPOSED LAND USE WILL BE AFFECTED BY POTENTIAL FUTURE MINING OR PRODUCTION ON THE LAND AND SURROUNDING AREA

PROVIDE A SUMMARY BELOW OF HOW HOLDERS OF PROSPECTING AND MINING RIGHT HOLDERS OR EXPLORATION AND PRODUCTION IN THE AREA HAVE DESCRIBED THE MANNER IN WHICH THEIR CURRENT OR FUTURE INTERESTS IN THE AREA WILL BE IMPACTED UPON BY THE PROPOSED DEVELOPMENT, INCLUDING ANY IMPEDIMENTS TO MINING OPERATIONS THAT ARE FORSEEN, IMPACTS ON THEIR ENVIRONMENTAL OBLIGATIONS, AND THE POTENTIAL FOR OBJECTIONS TO THEIR ACTIVITIES BY FUTURE OCCUPIERS OF THE PROPOSED DEVELOPMENT.

Herewith I, the person whose name and identity number is stated below, confirm that I am the Applicant or the person authorised to act as representative of the Applicant in terms of the resolution submitted with the application, that the information contained herein is true and correct.

Full Names and Surname

Identity Number