Application form Section 14(a) – Nature Conservation (Administration) Regulation 2006 OFFICIAL USE ONLY DATE RECEIVED Protected plant growing licence FILE REF Important information for applicants PROJECT REF COMPLETE FORM CORRECT AA COMPLETE FEE ADMINISTERING DISTRICT ENTERED BY [SIGNATURE] DATE This form is to be used to apply for a protected plant growing licence. Information requested will enable your application to be processed as prescribed by the Nature Conservation Act 1992. Your application must be assessed and a permit granted by the chief executive before you can proceed with the proposed activity. Your application may take up to 40 days to process. Before completing your application please read the information materials included with your application kit. Before lodging this application you should be familiar with the requirements of the Nature Conservation Act available on the Office of the Queensland Parliamentary Counsel website http://www.legislation.qld.gov.au. If you have queries about how to complete this form correctly or need guidance contact Permit and Licence Management on 1300 130 372. Fees and concessions In accordance with section 144 of the Nature Conservation (Administration) Regulation 2006, reduced fees are available for particular applications. Does the application relate to one of the following purposes? An educational purpose; or A scientific research purpose; or An activity directed at conservation; or Clearing to establish necessary property infrastructure; or A traditional owner activity. See section 144 of the Nature Conservation (Administration) Regulation 2006 for definitions of the eligible purposes. In accordance with section 155 of the Nature Conservation (Administration) Regulation 2006, a fee exemption is available for particular applications. Is the applicant is one of the following; A recreational plant society A voluntary conservation organisation A volunteer community organisation See section 155 of the Nature Conservation (Administration) Regulation 2006 for definitions of eligible applicants. Page 1 of 8 • 140807 ABN 46 640 294 485 Application form Protected plant growing licence PART A – LICENCE APPLICATION Applicant information A permit may only be granted to an individual or corporation. Please tick the appropriate box: AN INDIVIDUAL Complete Section 1 applicant details — then complete sections 3 to 13 A CORPORATION Complete Section 2 applicant details — then complete sections 3 to 13 1. Applicant details for an individual APPLICANT’S FAMILY NAME TITLE APPLICANT’S GIVEN NAME/S DATE OF BIRTH RESIDENTIAL ADDRESS (NOT A POST OFFICE BOX) POST CODE TELEPHONE (BUSINESS HOURS) MOBILE TELEPHONE (AFTER HOURS) EMAIL FACSIMILE POSTAL ADDRESS (WRITE ‘AS ABOVE’’ IF SAME AS RESIDENTIAL ADDRESS) POST CODE 2. Application details for corporations REGISTERED LEGAL ENTITIY NAME (NOT A BUSINESS TRADING NAME) TRADING NAME/S (IF APPLICABLE) REGISTERED BUSINESS ADDRESS (NOT A POST OFFICE BOX) POST CODE TELEPHONE (BUSINESS HOURS) FACSIMILE EMAIL WEBSITE POSTAL ADDRESS (WRITE ‘AS ABOVE’ IF SAME AS BUSINESS ADDRESS) POST CODE ABN / ACN / AN, OR TITLE AND SECTION OF LEGISLATION UNDER WHICH CORPORATION HAS LEGAL STATUS NAME OF PRINCIPAL OF CORPORATION SIGNATURE OF PRINCIPAL OF CORPORATION (or person authorised to sign on their behalf) Page 2 of 8 • 140807 DATE Department of Environment and Heritage Protection Application form Protected plant growing licence Details of nominated person in charge where the authorised activity is to be undertaken NOMINATED CONTACT PERSON’S FAMILY NAME TITLE NOMINATED CONTACT PERSON’S GIVEN NAME/S DATE OF BIRTH RESIDENTIAL ADDRESS (NOT A POST OFFICE BOX) POSTCODE TELEPHONE (BUSINESS HOURS) MOBILE TELEPHONE (AFTER HOURS) EMAIL FACSIMILE POSTAL ADRESS (WRITE “AS ABOVE” IF SAME AS RESIDENTIAL ADDRESS) POSTCODE 3. Have you previously held this type of permit? This may include permits in other States. Yes No If yes, state the permit number (if known) 4. What is the purpose of the harvest? PLANT PARTS WHOLE PLANTS Sustainable harvest of protected plant parts Sustainable harvest of protected plants to be used as stock plants Note: a growing licence will not be granted for the purpose of salvage of whole protected plants. 5. Plant details What plants does the application refer to? (If you require more space, attach a separate sheet of plant details) SCIENTIFIC NAME COMMON NAME CONSERVATION STATUS Page 3 of 8 • 140807 L – LIVING D – DEAD P – PARTS/ PRODUCTS (describe type of part) QUANTITY Department of Environment and Heritage Protection Application form Protected plant growing licence 6. Sustainable harvest plan A sustainable harvest plan is required for the harvest of all endangered, vulnerable, near threatened or special least concern plants, as listed in section 5 of this application (refer to section 10 for attachment requirements). Has a sustainable harvest plan been prepared in accordance with the protected plants assessment guideline? Yes No 7. Harvest of forest products Does the activity involve harvest of product under the Forestry Act 1959? Yes No If yes, do you have a forestry permit or licence, sales permit, or other resource entitlement? Yes No Please note that an approval under the Forestry Act 1959 is required prior to the approval of a protected plants growing licence. 8. What property or properties do you intend to take plants from? (If you require more space, attach a separate sheet) LOT ON PLAN DESCRIPTION AND ADDRESS LOCAL GOVERNMENT NAME PARISH NAME 9. Place of keeping plants ADDRESS Are protected plants to be used for trade? POSTCODE Yes No Note: Requirements for trading in protected plants are listed under the Nature Conservation (Wildlife Management) Regulation 2006. Under section 270 of the Nature Conservation (Wildlife Management) Regulation 2006, it is an offence to use a stock plant taken under a protected plant growing licence for trade. 10. Attachments For plants identified in section 5, list all documents in the space below. 1) A spatial representation of where protected plants are proposed to be harvested from, if not otherwise included in a sustainable harvest plan; Page 4 of 8 • 140807 Department of Environment and Heritage Protection Application form Protected plant growing licence 2) A sustainable harvest plan, prepared in accordance with the protected plants assessment guideline must be attached; 3) If the application relates to the harvest of seed or other propagative material from a protected plant that is endangered wildlife, or a protected plant of the family Cycadaceae or Zamiaceae, official qualifications or demonstrated ability to identify the plant must be attached; and 4) Other documents including maps containing information to support this application may also be attached if necessary. Note: A sustainable harvest plan is a plan about the harvest of protected plants and the ecological sustainability or benefits of the harvest. The sustainable harvest plan must be prepared in accordance with the protected plants assessment guideline. ATTACHMENTS (LABEL ALL ATTACHMENTS ALPHABETICALLY E.G. “ATTACHMENT A”) 11. Applicant suitability The licence may be granted if the applicant is an appropriate person to hold the licence, that is, if the applicant has the ability to carry out activities under the authority in a competent and ethical way. QUESTIONS DETAILS 1. During the past 10 years have you ever (in Queensland or elsewhere) been found guilty of any criminal offence or entered a plea of guilty in a Court? YES NO YES NO (Note: does not include simple traffic offences such as parking, speeding.) If yes, provide details of the offence/s. 2. Have you ever had an equivalent permit from another State or country that was suspended and/or cancelled? If yes, provide details about the permit, the date it was suspended and/or cancelled and reasons for suspension/cancellation. 12. Privacy statement Information you provide on this form is being collected by the Department of Environment and Heritage Protection to process and administer your application for a Protected plant growing licence, as authorised under section 14(a) of the Nature Conservation (Administration) Regulation 2006. Some information may be provided to the Departments of National Parks, Recreation, Sport and Racing; Agriculture, Fisheries and Forestry; or Health in order to investigate allegations of unlawful activity, biosecurity or health issues, if required. Information regarding your status as a holder of this type of permit may be provided to any party upon request. Your personal information will not be disclosed to any other parties unless authorised or required by law. More information on our commitment to privacy is available on our website: http://www.ehp.qld.gov.au/legal/privacy.html. Page 5 of 8 • 140807 Department of Environment and Heritage Protection Application form Protected plant growing licence 13 Declaration Note: If you have not told the truth in this application you may be liable for prosecution under the relevant Acts or Regulations. I do solemnly and sincerely declare that the information provided is true and correct to the best of my knowledge and I make this solemn declaration conscientiously believing the same to be true I understand that all information supplied on or with this application form 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 IF THE APPLICANT IS A CORPORATION, PLEASE INDICATE YOUR POSITION IN THE CORPORATION PART B – LANDHOLDER STATEMENT This section demonstrates landholder permission for the harvest of protected plants. The landholder and the applicant for a protected plant growing licence should be familiar with a Harvest Period Notice current at the time of application, if applicable. Is the applicant the landholder of the land? YES NO The applicant or the landholder of the land must complete this section. Landholder name(s) LANDHOLDER NAME(S): Contact person for the landholder CONTACT NAME: Contact person’s details POSITION: FULL POSTAL ADDRESS: TELEPHONE: Page 6 of 8 • 140807 FACSIMILE: Department of Environment and Heritage Protection Application form Protected plant growing licence ( ) EMAIL: Plant harvest details THE PURPOSE OF THE HARVEST AND THE LIST OF PLANTS TO BE TAKEN UNDER THE PROTECTED PLANT GROWING LICENCE. Landholder certificate I, PRINTED NAME OF TENEMENT HOLDERS Authorise the applicant to harvest plants from the land, and State that information supplied above is, to the best of my knowledge, true and accurate. SIGNATURE POSITION OF SIGNATORY (E.G. DIRECTOR, MANAGER, OWNER, PARTNER, CEO ETC.): DATE: PART C – APPLICANT CHECKLIST Application form completed and signed Please return to: Fees paid or enclosed Permit and Licence Management Spatial representation of plants subject to harvest (if applicable) Department of Environment and Heritage Protection Sustainable harvest plan (if applicable) GPO Box 2454 Brisbane Qld 4001 Enquiries: 1300 130 372 Evidence of ability to identify plant (if applicable) Facsimile: (07) 3330 5875 E-mail: palm@ehp.qld.gov.au Other documentation or qualifications (if applicable) Privacy statement acknowledged Please make all cheques payable to EHP. Page 7 of 8 • 140807 Department of Environment and Heritage Protection Application form Protected plant growing licence The Nature Conservation (Wildlife Management) Regulation 2006 may be obtained from the Office of Queensland Parliamentary Counsel website http://www.legislation.qld.gov.au Code of Practice or guidelines and Information sheet – Wildlife authorities and privacy may be obtained from the EHP website http://www.ehp.qld.gov.au/licences-permits/plants-animals or by contacting the EHP Referral Centre on 1300 130 372. Page 8 of 8 • 140807 Department of Environment and Heritage Protection