Section 32M, Prevention of Cruelty to Animals Act 1986
APPLICATION TO VARY A
SPECIFIED ANIMALS BREEDING LICENCE
Licence name and/or designation for which variation is being sought (obligatory):
SABL……... (Type licence number) Licence name: …….…………………………….. (Type licence name)
Please indicate variation type:
Application to change Licence Nominee, to be signed by person representing the licence holder
and by the new nominee (complete Parts A and B)
Change in Licence Nominee contact details (complete Part B)
Application to change licensed premises, to be signed by the Licence Nominee (complete Part C)
Application to change AEC details including new Terms of Reference (complete Part D)
Change in name of licence and/or institution officer details (complete Part E)
Complete the relevant part of this form only
PART A. VARIATION OF LICENCE NOMINEE
The licence holder ………...…………………………………………………………………………….
(Type name of licence holder, e.g. university, company)
Nominates the following person to be responsible for the obligations and requirements in respect of
the licence:
…………………………………………………………………... (Type name of new licence nominee)
from this date onwards: ............................................(Type date of effect of change in licence nominee)
Name, signature and position of person(s) authorised to sign this application on behalf of the licence
holder (e.g. vice chancellor of university or director, chief executive officer and/or secretary of
company):
Signatory #1 – Given name: …………..……………….... Surname: ………………………..……….
Position: …………………………..….. Signature: …………………....…… Date: ………..………..
Signatory #2 – Given name: …………..……………….... Surname: ………………………..……….
Position: …………………………..….. Signature: …………………....…… Date: ………..………..
Acceptance of nomination
I, ……………………………………………………………… (Type name of new licence nominee),
consent to being named to be responsible for the obligations and requirements in respect of the
licence. I agree to comply with all the relevant requirements of the Act and Regulations, the licence,
the Australian Code for the care and use of animals for scientific purposes and the Victorian Code of
practice for the housing and care of laboratory mice, rats guinea pigs and rabbits.
Date: ……………. Signature of Nominee: ......................................................................................
[The personal information on this application form, and any license that is issued following processing of this application, will be stored and used by
the Victorian Government for the purposes of administering the Prevention of Cruelty to Animals Act 1986 (the Act). You have the right of access to
this information by contacting the Department at the address mentioned on this application form. This information may be disclosed to another
government organisation for the purpose of administering or enforcing the Act or another relevant Act.]
PART B. CONTACT DETAILS FOR LICENCE NOMINEE
Title: …………….. ; Given name: …………………………….. ; Surname: ………………………
Postal address: ……………………………………………………………………………………….
Position in institution: ………………………………………………………………………………..
Phone: …………………… Fax: …………………… Email: ……………………………………...
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PART C. VARIATION OF PREMISES DETAILS
I, ……………………………………………….………………….. (Type name of licence nominee)
herein apply to amend the premises listed on the Specified Animal Breeding Licence to include:
Room
Floor
number
Building
Street address
AEC
inspection
date
[List all the premises (including pre-existing licensed premises) over which the entity has legal
occupancy and at which it is intended to carry out the breeding of specified animals. Attach
additional sheets as necessary.]
Signature of Licence Nominee: ……………….……………………………. Date: ………..………..
Name of AEC representative: ………………………..…………; Position: …………………………..
Signature of AEC representative: ………….………….……………………..…… Date: ………..…..
Note: premises that have not been inspected by the regulator within the previous 3 years must be
inspected by the regulator after AEC approval and prior to being listed on the licence.
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[The personal information on this application form, and any license that is issued following processing of this application, will be stored and used by
the Victorian Government for the purposes of administering the Prevention of Cruelty to Animals Act 1986 (the Act). You have the right of access
to this information by contacting the Department at the address mentioned on this application form. This information may be disclosed to another
government organisation for the purpose of administering or enforcing the Act or another relevant Act.]
PART D. VARIATION OF ANIMAL ETHICS COMMITTEE DETAILS
Name Animal Ethics Committee: ……………………………………...……………………………
Chair title: ……….. ; Given name: ………………………..; Surname: ……………………………
Postal address: ……………………………………………………………………………………….
Position in institution: ...……………………………………………………………………………..
Secretary title: …………….. ; Given name: …………………....; Surname: ………………………
Postal address: ……………………………………………………………………………………….
Phone:…………………… Fax: ……………………… Email: …………………………………...
Revised AEC member list, including additional sheets if necessary
Title
Name
Surname
Category or role (include chair category if they
function in one)
Voting?
New?
List proposed committee members including qualifications for the appropriate category (Australian
Code for the care and use of animals for scientific purposes), adding additional tables and lines as
necessary. Examples of acceptable qualifications are provided.
Category A (Veterinarian member)
Title: …………….. ; Given name: ………..…………....; Surname: ………..……..………..............
Proposed appointment date: ….…….……… Email address (voluntary): ……………...……………

Veterinary science qualifications (registrable as a practitioner in Vic): ..……..……...………..

Provide a brief description of recent experience relevant to the work to be undertaken under
the authority of the licence and AEC in Victoria. Please include dates.
……………………………………………...………..……….…….……………...…………………
……………………………………………………...………..…………….……………...………….
…………..…………………………………………...………..…………….……………...…...……,
or
[The personal information on this application form, and any license that is issued following processing of this application, will be stored and used by
the Victorian Government for the purposes of administering the Prevention of Cruelty to Animals Act 1986 (the Act). You have the right of access
to this information by contacting the Department at the address mentioned on this application form. This information may be disclosed to another
government organisation for the purpose of administering or enforcing the Act or another relevant Act.]

Provide a brief description of activities undertaken to gain familiarity with the biology and
clinical characteristics of animals used under the authority of the licence and AEC.
……………………………………………………...………..…………………………...…………
……………………………………………………...………..…………………………...…………
……………………………………………………...………..…………………………...…………
Category B (Researcher/teacher member)
Title: …………. ; Given name: …………….…………....; Surname: ……………..………..............
Proposed appointment date: ….…….… Email address (voluntary): …………..……….……………
Qualifications of proposed member to suit a Category B membership

Provide relevant qualification name(s), education institution name(s), and describe relevancy
to the work to be undertaken under the authority of the licence and AEC in Victoria.
……………………………………………………...………..……………….…………...…………
……………………………………………………...………..……………….…………...…………
……………………………………………………...………..……………….…………...…………

Provide a brief description of recent experience relevant to the work to be undertaken under
the authority of the licence and AEC in Victoria. Please provide dates.
……………………………………………………...………..………….………………...…………
……………………………………………………...………..……….…………………...…………
……………………………………………………...………..………….………………...…………
Category C (Animal welfare member)
Title: ………….. ; Given name: …………………….…....; Surname: ……………....……...............
Proposed appointment date: ….…….……… Email address (voluntary): …………….……………

Provide a brief description of activities undertaken indicating demonstrated commitment to,
and established experience in furthering the welfare of animals.
……………………………………………………...………..………………………..…....…………
……………………………………………………...………..……………………………..…………
………………..……………………………………...………..…………………………....…………
Provide a statement that the proposed member is not otherwise associated with licence holders
utilising this AEC.
……………………………………………………...………..…………………….……...…………
……………………………………………………...………..…………………………....…………
[The personal information on this application form, and any license that is issued following processing of this application, will be stored and used by
the Victorian Government for the purposes of administering the Prevention of Cruelty to Animals Act 1986 (the Act). You have the right of access
to this information by contacting the Department at the address mentioned on this application form. This information may be disclosed to another
government organisation for the purpose of administering or enforcing the Act or another relevant Act.]

Provide a statement that the proposed member is not involved in the care and use of animals
for scientific purposes
……………………………………………………...………..…………………………...…………
……………………………………………………...………..…………………………...…………

Provide a brief description indicative of active membership of a recognised animal welfare
organisation.
……………………………………………………...………..…………………………...…………
……………………………………………………...………..…………………………...…………
……………………………………………………...………..…………………………...…………

Provide a statement that the proposed member is considered by the animal welfare
organisation to be suitable to be a Category C member
……………………………………………………...………..…………………………...……….…
……………………………………………………...………..…………………………...……….…
……………………………………………………...………..…………………………...……….…
Category D (Wider community member)
Title: ………….. ; Given name: …………..…………....; Surname: …………..…………...............
Proposed appointment date: ….…….……… Email address (voluntary): …………….……………

Provide a statement that the proposed member is not otherwise associated with licence
holders utilising this AEC.
……………………………………………………...………..…………………………...………….
……………………………………………………...………..…………………………...……….…

Provide a statement that the proposed member has not been involved in the use of animals
in scientific or teaching activities either in employment or beyond undergraduate education.
……………………………………………………...………..…………………………...…………
……………………………………………………...………..…………………………...……….…

Provide a statement in this box that the proposed member does not fit the requirements of
any other AEC category.
……………………………………………………...………..…………………………...…………
……………………………………………………...………..…………………………...…………
Other member (e.g. person responsible for the routine care of animals)
Title: ………….. ; Given name: …………..…………....; Surname: ……………..………...............
Date of appointment: …….……… Email address (voluntary): ……………………………………
[The personal information on this application form, and any license that is issued following processing of this application, will be stored and used by
the Victorian Government for the purposes of administering the Prevention of Cruelty to Animals Act 1986 (the Act). You have the right of access
to this information by contacting the Department at the address mentioned on this application form. This information may be disclosed to another
government organisation for the purpose of administering or enforcing the Act or another relevant Act.]

Provide a brief description of the role of the member.
……………………………………………………...………..…..………………………...…………
……………………………………………………...………..…………………………...…………
EXAMPLES OF ACCEPTABLE AEC MEMBER QUALIFICATIONS
Category A (Veterinarian member)
 Recent experience relevant to activities of the institution –
Dr Black has been Animal Welfare Officer at Dubbo University since 2010, an institution
conducting similar lines of research to that authorised by this licence and being overseen by this
AEC or
 Familiarisation with animals used completed Dr Black has researched the animal biology, clinical characteristics and natural history in the
context of the activities undertaken by the licence. Additionally, Dr Black has discussed the
activities of the licence with the vet and animal care staff responsible for day to day animal
care.
Category B (Researcher/teacher member)
 recent experience in the use of animals in scientific or teaching activities Dr Clark has been Senior Lecturer in the Physiology Department to be covered by this licence
from 2009 onwards
Category C (Animal welfare member)
 demonstrated commitment to, and established experience in furthering the welfare of animals From 2010 to 2014 Mr Williams was instrumental in campaigning for improving the pound facilities
in his municipal area.
 not otherwise associated with the licence-holders utilising this AEC Mr Williams is not otherwise associated with licence-holders utilising this AEC
 not involved in the care and use of animals for scientific purposes Mr Williams is not involved in the care and use of animals for scientific purposes
 where possible, while not representing any organisation, active membership of a recognised
animal welfare organisation
Mr Williams has been member of Animal Welfare International for 10 years and secretary of the
St Havers branch for the last 2 years
 where possible nomination from that organisation
Mr Williams has been confirmed by Animal Welfare International (Australia) as suitable to be a
Category C member
Category D (Wider community member)
 not otherwise associated with the licence-holders utilising this AEC; Mr Smith is not otherwise associated with licence-holders utilising this AEC
 have not been involved in the use of animals in scientific or teaching activities either in
employment or beyond undergraduate education
[The personal information on this application form, and any license that is issued following processing of this application, will be stored and used by
the Victorian Government for the purposes of administering the Prevention of Cruelty to Animals Act 1986 (the Act). You have the right of access
to this information by contacting the Department at the address mentioned on this application form. This information may be disclosed to another
government organisation for the purpose of administering or enforcing the Act or another relevant Act.]
Mr Smith has not been involved in the use of animals in scientific or teaching activities either in
his employment or beyond his undergraduate education
 do not fit the requirements of any other AEC Category Mr Smith does not fit the requirements of any of Categories A to C.
Other member (e.g. person responsible for the routine care of animals)
Role:
Ms Klein is responsible for the routine care of animals to be used under a licence using this
committee
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Attach a copy of revised AEC terms of reference (TOR). In accordance with the Australian Code
for the care and use of animals for scientific purposes, the AEC TOR must include the following
provisions:
i. the scope of its [The AECs] responsibilities for ethical review, approval and monitoring of
animal care and use
ii. its [The AECs] institutional accountability
iii. its [The AECs] mechanisms of reporting
iv. the away in which it [The AEC] meets the requirements for categories if minimum
membership.
Type date of effect of change of TOR: …………………………………..
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PART E. NAME OF LICENCE AND/OR INSTITUTION OFFICER DETAIL VARIATION
New licence name: …………………………………………………………………………………..
If the licence holder has an institution officer who monitors a number of scientific procedure
licences (e.g. member of university research and ethics office), provide altered licensing officer
details.
Title: ………….. ; Given name: ……………..…………... Surname: ……………..………..............
Postal address: ……………………………………………………………………………………….
Phone:…………………… Fax: ……………………… Email: …………………………………...
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FORWARDING DETAILS
Forward signed Parts of this form by mail to:
Licensing & Audit
Biosecurity Assurance
475 Mickleham Rd,
ATTWOOD, VICTORIA 3049
Forward unsigned Parts of this form by email, fax
or mail to



Sp.Licensing@depi.vic.gov.au
(03) 9217 4416
The above address
[The personal information on this application form, and any license that is issued following processing of this application, will be stored and used by
the Victorian Government for the purposes of administering the Prevention of Cruelty to Animals Act 1986 (the Act). You have the right of access
to this information by contacting the Department at the address mentioned on this application form. This information may be disclosed to another
government organisation for the purpose of administering or enforcing the Act or another relevant Act.]
GLOSSARY OF TERMS (HYPERLINKED)
The licence holder
The licence holder is the legal entity that originally applied for the licence (e.g. the body corporate
as a company or university; or a natural person).
Return to form.
Licence Nominee
The Licence Nominee is the individual nominated by the institution to be legally responsible for
breeding of specified animals. This person should have a direct managerial role over personnel and
procedures associated with animal use. At universities, the department head is likely to be most
appropriate for this role. In a private institution, it might be the head of the breeding unit.
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Person authorised to sign on behalf of the applicant
The application form must be signed on behalf of the licence holder by a person authorised to
represent the corporation. This may be a vice chancellor for a university or chief executive officer
for a company. In the case where an individual is the licence holder, they should sign on their own
behalf. Space is provided for 2 signatories, for the case where a licence holder requires more than
one officer to sign on it’s behalf. Where the licence holder is a natural person, they may also take
the role of the Licence Nominee if they hold a suitable position.
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Premises
Premises that may be licensed are those that the licence holder legally occupies (owns, leases or
holds under formal agreement).
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AEC monitoring of interstate activities
The Australian Code for the care and use of animals for scientific purposes states that the AEC
monitors the care and use of animals by inspecting animals, animal housing and the conduct of
procedures, and/or reviewing records and reports. Where an institution nominates an AEC based
outside Victoria, it is required to demonstrate in the Terms of Reference how this requirement will
be fulfilled.
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Further information
Licensing & Audit
Biosecurity Assurance
(03) 9217 4425
Email: Sp.Licensing@depi.vic.gov.au
Webpage
[The personal information on this application form, and any license that is issued following processing of this application, will be stored and used by
the Victorian Government for the purposes of administering the Prevention of Cruelty to Animals Act 1986 (the Act). You have the right of access
to this information by contacting the Department at the address mentioned on this application form. This information may be disclosed to another
government organisation for the purpose of administering or enforcing the Act or another relevant Act.]