Applicant details

Name

Australian Business Number (ABN)

Organisation name

Position of applicant

Postal address

(include postcode)

Phone/Mobile

Do you have alternative contact details for invoicing?

YesNo

Contact name for invoice

Contact phone number for invoice

Email for invoice

Describe the action

Location of the action

(include grid reference, local government area)

Attach a map with location clearly identified

Full description of the action and its purpose

(e.g. environmental assessment, development, etc.)

Details of the area to be affected by the action

(in hectares)

Duration and timing of the action

(including staging, if any)

Is the action to occur on land declared as an 'area of outstanding biodiversity value'?

YesNo

List the species or communities to be harmed or picked

Scientific name

Common name

(if known)

Threatened or protected category

(i.e. critically endangered under Schedule 1 of the Biodiversity and Conservation Act, protected animal under Schedule 5 of the Biodiversity and Conservation Act)

Details of the number of individual animals, or proportion and type of plant material

(e.g. fertile branchlets, parts or whole plants)

Describe the condition of habitats and land use in and adjacent to the land to be affected by the action

Provide details of any known records of a threatened species in the same or similar known habitats in the locality

(include reference sources)

Provide details of any known habitat for a threatened species on the land to be affected by the action

(include reference sources)

Provide details of the amount of such habitat to be affected by the action proposed in relation to the known distribution of the species and its habitat in the locality

Provide an assessment of the likely nature and intensity of the effect of the action on the lifecycle and habitat of the species

Provide details of measures to avoid or minimise the effect of the action

Declaration

I confirm that the information contained in this application is correct. I hereby apply for a biodiversity conservation licence under the provisions of Part 2 of the Biodiversity Conservation Act 2016.

Applicant's name

Applicant's position and organisation

Applicant's signature

Date

Select your local office

Greater SydneyHunter and Central CoastIllawarraNorth EastNorth WestSouth EastSouth West