Application form
OFFICIAL USE ONLY
DATE RECEIVED
Application for approval as an auditor for
contaminated land
FILE REF
PROJECT REF
COMPLETE FORM
CORRECT AA
COMPLETE FEE
ADMINISTERING DISTRICT
ENTERED BY [SIGNATURE]
DATE
This approved form is to be used by an individual who is applying for approval
as an auditor, in order to undertake auditor functions under section 568(b) of
the Environmental Protection Act 1994 (the EP Act). This includes individuals
who are registered as an auditor for contaminated land in another Australian
jurisdiction and who are seeking approval through mutual recognition under the
Mutual Recognition (Queensland) Act 1992 (The MR (Q) Act).
Prior to making any application for approval as an auditor it is essential to refer
to the prescribed Queensland Auditor Handbook for Contaminated Land
Module 2: Auditor application requirements (EM1341) for guidance about what
information needs to be submitted with this application form. Applicants should
also have a pre-lodgement discussion with the administering authority to
discuss and clarify the application requirements.
1. Applicant details
Name
These contact details will be used for
correspondence from the
administering authority.
If approved, the applicant’s name,
company/organisation, registered
address, telephone and email
address will be made available online
by the administering authority on the
Queensland government website at:
http://www.qld.gov.au
Company/Organisation
Position
Registered Address for Company/Organisation
Telephone
Mobile
Email
Postal Address: (write ‘as above’ if the same as registered address)
Page 1 of 9 • 150924 • EM815
ABN46 640 294 485
Application form
Application for approval as an auditor for contaminated land
The principle of mutual recognition is
that a person who is registered in the
first State for an occupation is entitled
after notifying the local registration
authority of the second State for the
equivalent occupation, to be
registered in the second State for the
equivalent occupation.
2. Are you seeking approval as an auditor for contaminated land in
accordance with the mutual recognition principle under the
Mutual Recognition (Queensland) Act 1992?
Yes
Provide details below about your registration(s) as an auditor
for contaminated land in any other State and specify all of the
applicable States.
Attach certified copies of current registration(s) or
approval(s) and including any conditions or limitations
associated with the appointment(s) or approval(s).
No
If No, go to Question 8
Details
If you are seeking mutual recognition
of an auditor registration or approval
you hold interstate and you are
unable to meet the requirements
unders.19 of the MR (Q) Act, your
request will not be approved.
3. Have any of your past or present registrations as an auditor for
contaminated land in any Australian state ever been suspended or
cancelled?
Yes
You are unable to meet the statutory requirements under s.19
of the MR (Q) Act.
No
4. Are you currently subject to any disciplinary1, criminal or civil
proceedings in any Australian state in relation to your activities as
an auditor for contaminated land?
Yes
You are unable to meet the statutory requirements under s.19
of the MR(Q) Act.
No
5. Are you prohibited from acting as an auditor for contaminated
land in any Australian state as a result of criminal, civil or
disciplinary proceedings?
Yes
You are unable to meet the statutory requirements under s.19
of the MR(Q) Act.
No
6. Are you subject to any special conditions as an auditor for
contaminated land, as a result of criminal, civil or disciplinary
proceedings in any state?
Yes
1
You are unable to meet the statutory requirements under s.19
of the MR(Q) Act.
including any preliminary investigations or action that might lead to disciplinary proceedings.
Page 2 of 9 • 150924 • EM815
Department of Environment and Heritage Protection
Application form
Application for approval as an auditor for contaminated land
No
7. Do you give consent to the making of inquiries and the exchange
of information with the other state authorities regarding your
activities as an auditor, or any other matters relevant to your
request for mutual recognition?
If you are applying under the EP Act
and have answered ‘No’ to questions
8, 9, 10 or 11, you will not meet the
statutory requirements for making an
application under s. 570 of the EP
Act.
Yes
Go to Question 11.
No 
You are unable to meet the statutory requirements under s.19
of the MR(Q) Act.
8. Can you provide evidence that you have the qualifications
relevant to performing auditor’s functions for contaminated land?
Yes
Attach supporting information which meets the requirements
outlined in the Queensland Auditor Handbook for
Contaminated Land- Module 2: Auditor application
requirements (EM1341).
No
9. Can you provide evidence that you have the experience relevant
to performing auditor’s functions for contaminated land?
Yes 
Attach supporting information which meets the requirements
outlined in the Queensland Auditor Handbook for
Contaminated Land- Module 2: Auditor application
requirements (EM1341).
No
10. Do you have two suitable referees?
Yes 
Attach statements from two referees (as a minimum) in
accordance with the requirements outlined in the prescribed
Queensland Auditor Handbook for Contaminated Land
Module 2: Auditor application requirements (EM1341).
Also attach the curriculum vitae of each referee (unless the
referee is an auditor currently approved under Chapter 12
Part 3A of the EP Act).
No
11. Can you demonstrate knowledge of the Queensland legislation
including subordinate legislation and guidelines relevant to being
able to perform auditor functions for contaminated land?
Yes
Page 3 of 9 • 150924 • EM815
Attach the required statements which meet the requirements
outlined in the prescribed Queensland Auditor Handbook for
Contaminated Land Module 2: Auditor application
requirements (EM1341).
Department of Environment and Heritage Protection
Application form
Application for approval as an auditor for contaminated land
No
You must either be a member of an
organisation prescribed under
Schedule 8 of the Environmental
Protection Regulation 2008 or
commit to becoming a member if
approved.
12. Are you a member of an organisation prescribed under Schedule
8 of the Environmental Protection Regulation 2008?
Yes 
Include relevant details in the table below and attach a copy
of your current membership certificate or a statement of
membership issued by the prescribed organisation.
No 
Provide a statement that, if approved, you are willing to
become a member of an organisation prescribed under
Schedule 8 of the Environmental Protection Regulation 2008.
Name of prescribed
organisation
Type of membership
Membership start and end
date
13. Have you been convicted of any offences under the
Environmental Protection Act 1994?
Yes 
Provide details below.
No
Details (including the type) of offence
Applicable legislation
Date of offence
Outcome of the offence
14. Have you been convicted of any offences under another Act
involving misleading or fraudulent conduct?
Yes 
Provide details below.
No
Details (including the type) of offence
Page 4 of 9 • 150924 • EM815
Department of Environment and Heritage Protection
Application form
Application for approval as an auditor for contaminated land
Applicable legislation
Date of offence
Outcome of the offence
The insurance policy must be held by
you or on your behalf by the
company employing you. The policy
must not contain any exclusion that
may have the effect of limiting cover
for work carried out.
15. Do you hold adequate professional indemnity insurance?
Yes
State your insurer and your level of cover below (the minimum
is $5 million) and attach a copy of the current certificate of
insurance.
No 
Provide a statement that you will, if approved; obtain
professional indemnity insurance to a minimum level of $5
million and otherwise sufficient to cover the work you intend to
carry out as an auditor.
Insurer
Level of professional indemnity
insurance
$
To pay by credit card you will need to
provide your contact details and a
departmental officer will contact you
to process your payment. The
application fee is non-refundable.
16. Payment of fees2
(Persons seeking mutual recognition are not required to pay the
application fee. Go to Question 18—Statutory declaration for
persons seeking mutual recognition)
You may pay your fee via cheque, money order or credit card.
Select the payment method below:
Payment by cheque or money order made payable to the Department
of Environment and Heritage Protection (attached).
Please contact me (the applicant) for credit card payment.
Phone number:
2
These are the fees prescribed under Schedule 10, Part 3 of the Environmental Protection Regulation 2008.
Page 5 of 9 • 150924 • EM815
Department of Environment and Heritage Protection
Application form
Application for approval as an auditor for contaminated land
17. Declaration for persons applying under the Environmental Protection Act 1994
I declare that:

The information I have provided within this application is true and correct to the best of my knowledge.

I understand that it is an offence under section 480 of the Environmental Protection Act 1994 to give to
the administering authority a document containing information that I know is false, misleading or
incomplete in a material particular.

I understand that all information supplied with this application may be disclosed publicly in accordance
with the Right to Information Act 2009 and the Evidence Act 1977.
Applicant’s name
Applicant’s signature
Date
Page 6 of 9 • 150924 • EM815
Department of Environment and Heritage Protection
Application form
Application for approval as an auditor for contaminated land
18. Statutory declaration for persons seeking mutual recognition
Oaths Act 1867
QUEENSLAND
TO WIT
I,
(Name of person making this declaration)
of,
(Street address of the person making this declaration)
in the state of Queensland do solemnly and sincerely declare that:

The information I have provided within this application is true and correct to the best of my knowledge.

I understand that it is an offence under section 480 of the Environmental Protection Act 1994 to give to
the administering authority a document containing information that I know is false, misleading or
incomplete in a material particular.

I understand that all information supplied with this application may be disclosed publicly in accordance
with the Right to Information Act 2009 and the Evidence Act 1977.
And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the
provisions of the Oaths Act 1867.
Taken and declared before me, at
Insert location
this
day of
Insert day (e.g. 18th)
in the year
Insert month
Insert year
Signed
Signed
(Person making this declaration)
(Cross out whichever is not applicable) Justice
of the
Peace/Commissioner for Declarations/Notary
Public/Solicitor/Barrister/Conveyancer
Print name and registration number (if applicable)
Page 7 of 9 • 150924 • EM815
Department of Environment and Heritage Protection
Application form
Application for approval as an auditor for contaminated land
Checklist
Application form completed and the correct declaration signed
Question 2: For persons seeking mutual recognition only
Certified copies of current registration(s) or approval(s) and including any conditions or limitations associated
with the appointment(s) or approval(s) (if applicable)
Questions 8 & 9: Persons seeking mutual recognition are not required to complete this question

curriculum vitae attached

certified copy of tertiary qualification(s) attached

Statements 1 and 2 attached

work examples attached and prefaced with project synopsis template
Question 10: Persons seeking mutual recognition are not required to complete this question
2 referee statement attached (as a minimum) as well as each referee’s curriculum vitae (if the referee is not an
approved auditor in Qld)
Question 11: Statement 3 and 4 attached.
Question 12: Copy of current membership certificate is attached (a statement of membership issued by the
prescribed organisation will be accepted) or a statement that you will, if approved; obtain membership.
Question 15: Copy of the certificate of professional indemnity insurance attached (minimum is $5 million) or
a statement committing to obtaining adequate insurance upon approval.
Question 17: Persons seeking mutual recognition are not required to pay the application fee
Cheque/money order enclosed or phone number provided for credit card payment via phone.
How to lodge your application:
For efficiency it is preferred that your application and all mandatory supporting information is provided
electronically on a USB, CD, or DVD, accompanied by this form or a hardcopy covering letter. Applications can
be submitted by either:
Post:
Courier or hand delivery:
Permit and Licence Management
Permit and Licence Management
Department of Environment and Heritage Protection
Department of Environment and Heritage
Protection
GPO Box 2454, BRISBANE QLD 4001
Level 3, 400 George Street,
BRISBANE QLD 4001
Hours: 8.30 am—5.00 pm business days
Email:
palm@ehp.qld.gov.au
To allow for components of the application and mandatory supporting information to be readily identified and to
avoid administrative delay, be sure to abide by the following conventions:
Conventions for documents:

documents are to given a unique title or name, incorporating their date of completion (in dd_mm_yyyy
format)
Page 8 of 9 • 150924 • EM815
Department of Environment and Heritage Protection
Application form
Application for approval as an auditor for contaminated land

pages in each document are to be numbered consecutively

the page size is to be set to the ISO A-series standard

the resolution of PDF file should not be lower than 300 dots per inch

where practicable, any attachments, such as photos, figures or maps, are to be included as part of the
primary document

colour and black and white information should be able to be appropriately reproduced.
Conventions for electronic files:



Mandatory supporting information should be separate PDF files titled:
o
curriculum vitae
o
certified copy of tertiary qualification(s)
o
Statements 1, 2, 3 or so on
o
work examples 1, 2, 3 and so on
o
PI Insurance policy
o
Membership of prescribed organisation
Where any of these are comprised of more than one document a folder should be created and titled as
per the above with each PDF file in the folder given the same title as the individual PDF document.
PDF files should not be encrypted or require password access or be dependent on external
attachments for legibility.
Conventions for submission via email:



The subject line of the email should be ‘Application for approval as an auditor for contaminated land’.
The file size limit for submission via email is 14MB. Any submission via email which exceeds 14MB will
need to be broken down into separate emails, with each email clearly labelled Part X of X (e.g. Part 1 of
2), included in the subject line of the email.
Email attachments must be clearly titled and readily identifiable. Where mandatory supporting
information such as a work example is comprised of more than file, each attachment should be titled in
the following manner:
Title (e.g. Work example 1) _ Part X of X (e.g. Part 1 of 2) _ Title of the document
Privacy statement
The Department of Environment and Heritage Protection (the department) is collecting your personal information, and where applicable the
personal information of referees, to determine your suitability as an auditor under Chapter 12 Part 3A of the Environmental Protection Act
1994 (EP Act). The information will only be accessed by authorised employees within the department and a technical expert under contract
with the department to provide advice on some components of your application. The contract with the technical expert requires that the
information only be used for that purpose, and that he or she not otherwise use or disclose the information. If your application is approved ,
your name, organisation, business address, telephone number and email address will be disclosed on the Register of Approver Auditors
which will be publicly available on the relevant Queensland Government website. This disclosure is authorised under section 540A of the
EP Act. The information provided on this form will not otherwise be used or disclosed unless required or authorised by law. For information
about privacy matters email: privacy@ehp.qld.gov.au or telephone: (07) 3330 5436.
Page 9 of 9 • 150924 • EM815
Department of Environment and Heritage Protection