EPA FORM
Application for assessment of a proposal under the assessment
bilateral agreement
PURPOSE OF THIS FORM
Under the assessment bilateral agreement between the Commonwealth of Australia and the State of Western
Australia, proponents are required to apply1 to the Environmental Protection Authority (EPA) for a proposal to
be assessed under the agreement. If an application has not been made through the referral form, submission
of this completed form fulfils the requirement of the agreement.
Name of proponent
Name of proposal
Proponent contact for the
proposal:
 Name, physical address,
phone, email
Consultant for the proposal (if
applicable):
 name, address, phone,
email
PART 1
Has the action been referred under the EPBC Act?
No ☐
When will you refer the action under the
EPBC Act?
Date:
Go to Part 2
Yes ☐
When was the action referred under the
EPBC Act and what is the reference number?
Date:
Continue below
Has a decision been made under the EPBC Act as to
whether or not the action is a controlled action?
Is the action a controlled action?
1
Reference No.
No ☐
Go to Part 2
Yes ☐
Continue below
No ☐
An assessment under
the bilateral agreement
is not required – do not
submit this form.
Yes ☐
Continue below
Schedule 1, Clause 5.3(b)(i) of the Bilateral agreement made under section 45 of the Environment Protection and Biodiversity Act 1999
(Cth) relating to environmental assessment.
What are the EPBC Act controlling provisions identified in the notification of the controlled action decision?
Listed threatened species and ecological communities
☐
Listed migratory species
☐
Declared Ramsar wetlands
☐
National heritage places
☐
Word heritage properties
☐
Nuclear actions
☐
Commonwealth marine areas
☐
Commonwealth land
☐
Water resources
☐
PART 2
Application by proponent for assessment under Bilateral Agreement
By signing below you acknowledge that you are applying for the proposal to be assessed under the Bilateral
agreement made under section 45 of the Environment Protection and Biodiversity Conservation Act 1999
(Cth) relating to environmental assessment.
I, ………………………………………………., (full name) declare that I am authorised on behalf
of…………………………………………. (being the person responsible for the proposal) to
submit this form and further declare that the information contained in this form is true and not
misleading.
Signature:
Name (print):
Position title and organisation:
Date:
Please return completed form to the Environmental Officer (EIA Improvement) on
info@epa.wa.gov.au.