Geological & Mining Cadastre Division MRAM pledge application registration code:

Mineral Resources Authority X/MV - ………. - ……. - PL

Official Reference for Pledgee

Name of Reference: (required being legal personnel) ………………………………………………………………………………………………….

Name of Director: ……………………………………………………………………………………………………………………….(Surname, Last name)

Official contact details:

Address: …………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………………

Postal address: ………………………………………………… Postal box: ..…………………………………………………………………………..

Telephone: ……………………………….. Fax: …………………………………………. E-mail: ……………………………………………………..

Decision-making body of
applicant: .............................................................................................................................................................................
.........................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................

Stamp
Applicant: ……………………………….. / /
(Name) (Signature)

Form K-15