LRG Visiting Lease Notification Form

LRG Visiting Lease Notification Form

Please use this form to notify the committee of your intention to attend one or more of LRG's leases. All member's names, member numbers and vehicle details must be recorded on the form. Each member must complete a separate form, unless members from the same family or a Child or Associate member is travelling with an Ordinary member in the same vehicle, or several members are travelling together in the same vehicle. All members must sign the form.
Members please note:

Prior to travelling to any of LRG’s leases, it is the responsibility of all LRG members to notify the Pastoral Lease Holder (PLH) that LRG leases are on, of your intention to visit a lease.

Pastoral Lease Holder details can be obtained from the Department of Mines, Petroleum and Exploration (DMPE) by phoning (08) 9222 3333.

PLH details may include an email address, landline or mobilephone number. Sending an email, leaving a message on an answering machine or sending a text message to a mobile number is sufficient to ensure your obligation for notifying the PLH.
If you require assistance to complete this Visiting Lease Notification Form, please ask for help via the LRG Facebook page.
Member #1's Name

First NameLast Name
Member's Number and Membership Class

Member's NumberMembership Class (Child, Junior, Associate, Ordinary)
Member #2's Name

First NameLast Name
Member's Number and Membership Class

Member's NumberMembership Class (Child, Junior, Associate, Ordinary)
Member #3's Name

First NameLast Name
Member's Number and Membership Class

Member's NumberMembership Class (Child, Junior, Associate, Ordinary)
Member #4's Name

First NameLast Name
Member's Number and Membership Class

Member's NumberMembership Class (Child, Junior, Associate, Ordinary)
Member's Vehicle and Caravan/Camper Trailer Registration

Vehicle RegistrationCaravan/Camper Trailer Registration (if applicable)
Enter the Lease number you are visiting: Lease number*
Expected Date of Arrival at Lease

DayMonthYear
Date of Arrival
Expected Date of Departure from Lease

DayMonthYear
Date of Departure
Any Comments or General Information for the Committee:
Enter any comments here
Member #1's Signature*

Clear
Member #2's Signature (if applicable) If a Child, Junior or Associate member under 18 years old, a parent/guardian must sign here.

Clear
Member #3's Signature (if applicable) If a Child, Junior or Associate member under 18 years old, a parent/guardian must sign here.

Clear
Member #4's Signature (if applicable) If a Child, Junior or Associate member under 18 years old, a parent/guardian must sign here.

Clear
Should be Empty: