1.Purpose of application

Select one

Apply for a new LicenceExtend or vary a current LicenceUpdate details

List the native animals presenting a threat to safety, property damage or economic hardship and estimate the total number present and the number requested to be harmed to reduce the impact.

Species (common name)

Estimated number on the property

Number requested to be harmed

Please specify

2. Applicant details

For the property detailed in this application, you are (choose one)

the owneran occupier (includes manager)the owner/occupier

Company name (if applicable)

Full name

Date of birth

Postal address

Contact phone (daytime)

Firearms licence number

Firearms licence expiry date

Firearms category

If you have previously held a Landholder licence to harm, state the licence number

Start date

End date

Q1 Have you been investigated or convicted of an offence in the last 10 years in relation to any law concerning the protection, conservation or management of native species or ecological communities?

YesNo

Q2 Have you had a biodiversity conservation licence or similar permit suspended or cancelled?

YesNo

4. Application for a general licence to harm

Complete the application for a general licence to harm if a person other than the landholder is required to carry out the authorised harm on the property. This licence is required as part of the landholder licence to harm native animals, is site specific and will be issued by the local NPWS Area office for the same period as the landholder licence.

Professional pest management operators with a non-site-specific licence issued by NPWS Wildlife Team and renewed annually may be used for some situations. For more information see catch and release licences.

Company name (if applicable)

Nominated person’s name

Date of birth

Postal address

Contact phone (daytime)

Firearms licence number (if applicable)

Firearms licence expiry date

Firearms category

If you have held or currently hold a biodiversity conservation licence, such as a General licence, state the most recent licence number

Start date

End date

Q1 Have you been investigated or convicted of an offence in the last 10 years in relation to any law concerning the protection, conservation or management of native species or ecological communities?

YesNo

Q2 Have you had a biodiversity conservation licence or similar permit suspended or cancelled?

YesNo

5. Declaration by applicant

I the applicant, applying for this landholder’s licence to harm native animals, a class of biodiversity conservation licence under Part 2 of the Biodiversity Conservation Act 2016, acknowledge that it is an offence under the Biodiversity Conservation Act 2016 to provide false or misleading information in, or in connection with this application and I state the information I have provided is true and correct. By signing this application, I also acknowledge I will be required to comply with conditions of my licence, and any other statutory obligations.

Signature

Date

6. Declaration by nominated person for authority to harm

I, the nominated person for authority to harm a protected native animal acknowledge that it is an offence under the Biodiversity Conservation Act 2016 to provide false or misleading information in, or in connection with this application and I state the information I have provided is true and correct. By signing this application, I also acknowledge I will be required to comply with conditions of the Licence, and any other statutory obligations.

Signature

Date

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