Client Profile Form
All information submitted will be kept confidential.
Client Full Name
*
First Name
Middle Name
Last Name
Client Address
Street Address
Area
Town/Village
Region
Client Phone Number
*
Please enter a valid phone number.
Format: (+255) 000-000-000.
Client Email
example@example.com
Client Company Name
Client Identification Document
Please Select
Passport
Driving License
National ID
Client Identification Number
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Type of Business Activity
Primary Mining License
Mwalo / Crushing Site
Processing License - CIP/CIL
Processing License - VAT Leeching
Processing License - Elution
Mineral Refinery
Other
Client Mwalo Certificate No.
Mwalo Certificate (Upload Scanned Document)
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Crushing Site Location Coordinates
Crushing Capacity
Tonnes per week
Number of Operating Ball Mills
Primary Mining License No.
Primary Mining License Certificate (Upload Scanned Document)
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Mining Location Coordinates
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Identified Logistics Company Name
Transporter of Tailings or Ore
Logistics Phone Number
Please enter a valid phone number.
Format: (+255) 000-000-000.
Chemist Full Name
First Name
Last Name
Chemist Phone Number
Please enter a valid phone number.
Format: (+255) 000-000-000.
Identified VAT Leeching Plant Name
VAT Leeching Plant Location
Geograpical Coordinates
VAT Leeching Contact Name
First Name
Last Name
VAT Leeching Contact Phone Number
Please enter a valid phone number.
Format: (+255) 000-000-000.
Distance to VAT Leeching Plant
VAT Leeching: Tank Size
VAT Leeching: Number of Tanks
Identified Elution Plant Name
Elution Plant Location
Geographical Coordinates
Elution Plant Contact Name
First Name
Last Name
Elution Contact Phone Number
Please enter a valid phone number.
Format: (+255) 000-000-000.
Elution: Tank Size
Elution: Number of Tanks
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How long have you been mining at the current project?
Enter the total number of months.
What is your mining extraction method at the current project?
Shaft
Open Pit
Open Pit with Shaft
What are your operational means at the current project?
Mechanical Winch
Manual Labour
What is your main source of energy at the current project?
Diesel Generator
TANESCO Electricity
Expected PPM target
PPM - Grams per Tonne
Rock Sample PPM Test
Client Test
Aurum Test
Sample Analytical Test of Rock Sample
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Amount of Tailings present at the current project?
Time taken to accumulate tailings at the current project?
PPM of tailings at the current project?
PPM - Grams per Tonne
Sample Analytical Test of Tailings
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Do you accumulate 'free gold' within your processes?
Yes
No
Sometimes
What is your targeted ratio of 'free gold' to 'processed tailings'?
PPM - Grams per Tonne
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Amount of funds requested.
Give a short description on how the funds will be utilised.
Other information or requirements.
Signature
Submit
Submit
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