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 (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

Date
Name: :
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:
 Omgewingsbestuursprogram:
Aansoek om Petroleum Eksplorasiereg,
Application for Petroleum Exploration Right, Karoo-kom
Falcon Oil & Gas Bpk
PASA Verwysingsnommer: 12/3/208/1

KOMMENTAARVORM

Vul asseblief die vorm in en handig dit in per hand, pos, faks of e-pos aan Danélle Fourie of Lindsay Shand by SRK
Consulting. Kommentaar wat voor of op 9 Februarie 2011 ontvang word sal in die Publieke Deelnameverslag
aangeteken word, wat as addendum by die EMP ingedien sal word.
Faks: 021 685 7105 Tel: 021 659 3060,
E-pos: dfourie@srk.co.za / lshand@srk.co.za
Adres: SRK Consulting, Postnet Suite #206, Privaatsak X18, Rondebosch, 7701.
SKRYF ASSEBLIEF DUIDELIK

Naam: Datum:
Organisasie (indien enige):
Hoedanigheid (indien van toepassing):
Posadres:

Poskode:
Telefoonnommer: Faksnommer:
E-pos:
Word u eiendom gelys in die Agergrondinligtingdokument as ingesluit in Falcon se Plan vir die Seismiese Opname?

Ja Nee Onseker Indien Ja of Onseker, voltooi asseblief:

Plaasnaam (volgens Eiendombewys)

Plaas- en gedeeltenommer(s):
Registrasie Afdeling: Provinsie:

U KAN ENIGE VOORLOPIGE KOMMENTAAR, VRAE OF KWESSIES WAT U WIL OPPER HIERONDER OF OP ‘N APARTE BLADSY
AANTEKEN: