Environmental Management Programme:

Application for Petroleum Exploration Right, Karoo Basin

Falcon Oil & Gas Ltd
PASA Reference Number: 12/3/208/1

COMMENT FORM

Please complete and submit this form by hand, post, fax or email to Danélle Fourie or Lindsay Shand at SRK
Consulting. Comments received on or before 9 February 2011 will be included in Public Participation Report, which
will be submitted as an addendum to the Environmental Management Programme Report (EMP).
Fax: 021 685 7105 Tel: 021 659 3060,
E-mail: dfourie@srk.co.za / lshand@srk.co.za
Address: SRK Consulting Postnet Suite #206, Private Bag X18, Rondebosch, 7701.
PLEASE PRINT CLEARLY

Name: Date:
Organisation (if any):
Capacity (if applicable):
Postal address:

Postal code:
Telephone number: Fax number:
E-mail:
Is your property listed in the Background Information Document as included in Falcon’s Seismic Survey Plan?

Yes No Unsure If Yes or Unsure, please provide:

Farm name(s) (as per Title Deeds):

Farm/Erf and Portion Number(s)
Registration Division: Province:

ANY COMMENTS, QUERIES OR CONCERNS THAT YOU WISH TO NOTE CAN BE PROVIDED IN THE SPACE BELOW AND/OR ON A
SEPARATE PAGE: