Policy and Conservation Advice Branch,
Department of Primary Industries, Parks, Water and Environment
PERMIT APPLICATION FORM
To Apply for the ‘Taking’ of Threatened
Flora and Fauna
(Issued under Section 29 of the Nature Conservation Act 2002, Regulation 4(3)(a) of the Threatened Species
Protection Regulations 1996, Regulation 28 of the National Parks and Reserved Land Regulations 2009,
Regulation 22(1) of the Crown Lands Regulations 2011 and/or Part 3 of the Wellington Park Regulations 1999)
For the purposes of this permit ‘Take’ includes destroy or damage a plant, and take, destroy or damage any fruit,
seed, product or other plant parts, nests, fauna or products of wildlife.
Permit Type: Development Activity -  Consultant -  Flora -  Fauna - 
For permits required for scientific research or educational purposes please use the relevant form found at:
http://dpipwe.tas.gov.au/conservation/publications-forms-and-permits
CONTACT DETAILS
Surname
Given Names
Title
Organisation/Institution
Postal
Address
Street
Address
Contact
Details
Phone
Mobile
Email
Names and addresses of all those involved with the project who will also require a permit. For projects
undertaken by large organisations, please provide name and title of the head of the organisation and the
name of the organisation.
PROJECT DETAILS
Short title of project (for development proposals, quote the name (including author and date) of the relevant
report.
Proposed start date
End date
Provide a brief description of the proposed activity and summary of any expert advice that has been
provided.
# Please attach any relevant reports/surveys relevant to this application (e.g. Environmental Reports and/or surveys)
Location:
Address of Development
Grid Reference
Easting
Northing
PID and/or Title Number
Map: Attach a map showing the property, the footprint of the development, the locations of threatened
flora/fauna to be ‘Taken’ and locations of threatened flora/fauna on the property that will fenced off/undisturbed.
The map must be legible (i.e. showing scale, map sheet number and easting/northing and datum grids and/or
the PID and be in colour or easily read in black/white)
Land Tenure (tick all that apply):
Private .................................. 
Reserve ................................ 
Crown Land ......................... 
Conservation Covenant ....... 
Other:
List species/products to be ‘Taken’ including the estimated number of individual flora/fauna or wildlife
products to be ‘Taken’ and the type and quantity of material (e.g. foliage, cuttings, nest) required. (Attach a
list if insufficient space).
Scientific Name
Common
Name
Number
to be
Taken
Type of
Impact
Contextual Information
(e.g. local population size and proportion of
population that will be impacted upon)
What mitigation measures have been implemented/are proposed to minimise impact? (e.g. avoidance,
relocation, rehabilitation etc.)
Location/s where the plant material, fauna or products taken will be used or lodged (e.g. herbarium,
museum)
Have you previously been issued with a permit to ‘Take’ Native Flora/Fauna requiring, as one of the
conditions that data be entered into the NVA and/or a permit activity report be submitted?
If yes please provide permit number
The data must be entered into the NVA and/or report must be completed and submitted to the Policy and
Conservation Advice Branch or further permits may not be issued.
Data entered/Report submitted?
Yes
No
If no, why not?
Signature of Applicant
Date
Please Read Carefully: The Department retains the authority to reject any permit application and also to apply
conditions to any permit issued. Allow 4 weeks for processing of applications. Permission must be sought
from the relevant land manager(s) to access land.
Permit Applications can be e-mailed or posted to:
Policy and Conservation Advice Branch, Natural and Cultural Heritage Division
ConservationAssessments@dpipwe.tas.gov.au
Phone 03 6165 4392
Department of Primary Industries, Parks, Water and Environment, GPO Box 44 Hobart, TAS 7001
1.
Personal information will be collected from you for the purpose of managing Tasmania’s flora/fauna and will be used by
DPIPWE for assessing, considering, advising upon, managing and/or determining the relevant application and may be
used for other purposes permitted by the Crown Lands Act 1976, National Parks and Reserves Management Act 2002,
Nature Conservation Act 2002, Threatened Species Protection Act 1995 and Wellington Park Act 1993 and regulations
made under these Acts.
2.
You are required to provide this information by the Crown Lands Act 1976, National Parks and Reserves Management
Act 2002, Nature Conservation Act 2002, Threatened Species Protection Act 1995 and Wellington Park Act 1993 and
regulations made under these Acts. Failure to provide this information may result in your application not being able to be
processed or the service not being able to be provided.
3.
Your personal information will be used for the primary purpose for which it is collected, and may be disclosed to
contractors and agents of the Natural and Cultural Heritage Division, law enforcement agencies, courts and other
organisations authorised to collect it.
4.
Your basic personal information may be disclosed to other public sector bodies where necessary, for the efficient
storage and use of the information.
5.
Personal information will be managed in accordance with the Personal Information Protection Act 2004 and may be
accessed by the individual to whom it relates, on request to DPIPWE. You may be charged a fee for this service.