APPLICATIONform
Request for an exemption from condition(s)
of title—petroleum exploration permit
Under Part 2.11 of the Offshore Petroleum and Greenhouse Gas Storage Act 2006.
In making an application please refer to the title instrument and Offshore Petroleum and Greenhouse Gas
Storage Act 2006. The Offshore Petroleum Exploration Guideline: Work-Bid contains further details in
respect of applications for exemptions.
Title and titleholder details
Title number
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(A separate application is required for each title)
Titleholder(s)
ASIC ACN/ARBN No:
(Company or Individual Name(s))
(if applicable)
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%
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%
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%
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%
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%
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%
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%
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
www.nopta.gov.au
Interest (%)
(Must total 100%)
APPLICATIONform
Work program commitment for which the exemption applies
The titleholder(s) should outline only the permit year(s) to which the exemption applies.
The primary term work program can be entered as individual years (e.g. 1, 2, 3) for permits granted prior to
1 June 2015 or as a block of years (e.g. 1–3) for permits granted after 1 June 2015 (or where the original
primary term of a permit granted prior to 1 June 2015 has been changed to a block of years as a result of a
variation application)—refer to the title instrument.
Note: Additional rows may be added for multiple activities within a permit year(s).
Year
Start
date
End
date
Activity
quantity
and unit
Activity description
Indicative
value A$
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Application fee payment
The correct application fee must accompany the application (pursuant 695L of the Act and Schedule 6 of the
Offshore Petroleum and Greenhouse Gas Storage (Resource Management and Administration) Regulations
2011). For more details on the methods of payment, refer to www.nopta.gov.au/cost.
Has the application fee been paid or accompanied the application?
(Include copy of evidence of payment of the application fee)
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
www.nopta.gov.au
Choose an item.
APPLICATIONform
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
Applicant contact details
Company name
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Company address
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Postal address (if not the same as above)
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Primary contact name
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Position held
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Phone
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Email
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Alternative contact name (if required)
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Position held
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Phone
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Email
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The following details should be attached to an application
Checklist
1
Description
Attached
Details of the exemption requested and reasons for the application, including:

the permit year(s) or activity for which the exemption is sought

where applicable, outline the effect on any subsequent years.
☐
2
Copy of evidence of payment of the application fee.
☐
3
A statement of any other matters the applicant wishes to be considered.
☐
4
Figures in the text should be legible, and should also be provided as separate files in an
attached appendix at a resolution of at least 300 dpi. If applicable, seismic sections should
be included with and without interpretation.
☐
Submission details
For details on how to submit your application please refer to http://www.nopta.gov.au/forms/index.html.
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
www.nopta.gov.au
APPLICATIONform
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
Signatures
Executed in accordance with subsection 264(1) of the Offshore Petroleum and Greenhouse Gas Storage
Act 2006. Each titleholder must have a representative authorised by each titleholder sign below (unless a
nomination has been made under subsection 775B(2) of the Offshore Petroleum and Greenhouse Gas
Storage Act 2006).
Note: if there is insufficient space allowed please attach additional pages.
Nomination made under subsection 775B(2)
Executed by
Executed by
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Company Name
Company Name
Signature
Signature
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Date
Date
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Full name (please print)
Full name (please print)
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Position
Position
OR where the applicant is an individual
Executed by
Executed by
Signature
Signature
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Date
Date
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Full name (please print)
Full name (please print)
www.nopta.gov.au
APPLICATIONform
And/or
Where the applicant(s) are a company
Executed by
Executed by
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Company Name
Company Name
Signature
Signature
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Date
Date
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Full name (please print)
Full name (please print)
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Position
Position
Executed by
Executed by
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Company Name
Company Name
Signature
Signature
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Date
Date
PERTH
Alluvion Building
Level 8
58 Mounts Bay Rd
Perth WA 6000
GPO Box 7871
Perth WA 6850
T: 08 6424 5300
Click here to enter text.
Click here to enter text.
Full name (please print)
Full name (please print)
Click here to enter text.
Click here to enter text.
MELBOURNE
Level 1
451 Lt Bourke St
Melbourne VIC 3000
GPO Box 4634
Melbourne VIC 3001
T: 03 8199 0300
Position
Position
www.nopta.gov.au