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Department of Environment and Heritage Protection
Application form
Section 12(d) — Nature Conservation (Administration) Regulation 2006
OFFICIAL USE ONLY
DATE RECEIVED
Rehabilitation permit
FILE REF
PROJECT REF
Important information for applicants
This form is to be used to apply for a rehabilitation permit. Information
COMPLETE FORM CORRECT AA requested will enable your application to be processed as prescribed by the
Nature Conservation Act 1992. Your application must be assessed and a
COMPLETE FEE permit granted by the chief executive before you can proceed with the
proposed activity. Your application may take up to 40 business days to
ADMINISTERING DISTRICT
process.
The permit holder is required to release the animal/s held under this permit into
ENTERED BY [SIGNATURE]
a prescribed natural habitat in the wild as soon as the animal is
rehabilitated/fit/old enough and able to live in that habitat.
DATE
Applicants must be able to demonstrate their skills, knowledge and ability
before being issued with a permit. The chief executive can refuse to grant a
rehabilitation permit if the applicant does not satisfy the chief executive that
they can carry out the activities under this authority.
Before completing your application please read the information materials
included with your application kit and contact Permit and Licence
Management on 1300 130 372 to discuss any issues. 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.
Applicant information
A wildlife authority may only be granted to an individual or corporation (only if the corporation has an office
within Queensland). Please tick the appropriate box:
AN INDIVIDUAL Complete Section 1 applicant details — then complete sections 3 to 11
A CORPORATION Complete Section 2 applicant details — then complete sections 3 to 11.
1. Applicant details for an individual
APPLICANT’S FAMILY NAME TITLE
APPLICANT’S GIVEN NAME/S DATE OF BIRTH
Page 1 of 8 • 121026
Department of Environment and Heritage Protection
www.ehp.qld.gov.au ABN 46 640 294 485
Application form
Rehabilitation permit
RESIDENTIAL ADDRESS (NOT A POST OFFICE BOX) POSTCODE
TELEPHONE (BUSINESS HOURS) MOBILE FACSIMILE
TELEPHONE (AFTER HOURS) EMAIL
POSTAL ADDRESS (WRITE ‘AS ABOVE’’ IF SAME AS RESIDENTIAL ADDRESS) POSTCODE
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) POSTCODE
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) DATE
Details of nominated person in charge where the licensed 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 FACSIMILE
TELEPHONE (AFTER HOURS) EMAIL
Page 2 of 8 • 1201026 Department of Environment and Heritage Protection
Application form
Rehabilitation permit
POSTAL ADDRESS (WRITE “AS ABOVE” IF SAME AS RESIDENTIAL ADDRESS) POSTCODE
Note: In accordance with the Code of Practice — Care of orphaned, sick or injured protected animals by wildlife
care volunteers, when applying for a group permit the Code states that ‘membership lists are updated and
forwarded annually to Permit and Licence Management’. A current membership list must accompany this
application form.
3. Are you between 13 and 18 years of age?
A permit can be granted to a child of 13 years or over. The name and address of the child’s parent or guardian
must be specified in the permit. The parent or guardian must live at the same address as the applicant.
No
Yes If yes, a parent or legal guardian must complete the following guardian details.
GUARDIAN’S FULL NAME DATE OF BIRTH
GUARDIAN’S RESIDENTIAL ADDRESS POSTCODE
TELEPHONE (BUSINESS HOURS) MOBILE FACSIMILE
TELEPHONE (AFTER HOURS) EMAIL
GUARDIAN’S SIGNATURE DATE
4. Have you previously held this type of permit?
This includes permits held in other States.
Yes No
IF YES, STATE THE PERMIT NUMBER (IF KNOWN)
5. Place of keeping wildlife?
The permit can be granted for one place only.
ADDRESS (WRITE “AS ABOVE” IF SAME AS RESIDENTIAL / REGISTERED BUSINESS ADDRESS) POSTCODE
LOCAL GOVERNMENT AREA
Page 3 of 8 • 1201026 Department of Environment and Heritage Protection
Application form
Rehabilitation permit
6. How do you intend to obtain the animal(s) concerned?
If you already have an animal at the time of making this application, please note that under the Nature
Conservation (Wildlife Management) Regulation 2006, you must either notify a conservation officer and deal
with the animal in the way directed, or give the animal to the holder of a rehabilitation permit for the animal (e.g.
licensed local wildlife care group) within 72 hours of taking possession of the animal.
As an injured animal
As a sick animal
As an orphaned animal
From spotter catcher activities
Other (please give details in the space provided below)
7. Do you have any experience in wildlife care/rehabilitation or spotter catcher
activities?
A rehabilitation permit can only be issued if the applicant is an appropriate person to hold the permit, i.e. if the
applicant has the ability to carry out activities under the permit in a competent and ethical way. For wildlife care
rehabilitation permits if you do not have any experience it is recommended that you contact your local wildlife
care group or experienced rehabilitator for guidance about possible endorsement under their permit.
No Do not proceed, contact a local wildlife care group/experienced carer for assistance, or
Yes Please provide the following information:
For a wildlife care rehabilitation permit please supply the following details:
What recognised training courses have you attended and when? (Supply copies of certificates.)
What species did you care for in the past?
Length of experience? (Minimum of 2 years demonstrated experience required)
What facilities/caging do you have available for wildlife rehabilitation?
Page 4 of 8 • 1201026 Department of Environment and Heritage Protection
Application form
Rehabilitation permit
How do you intend to keep up-to-date with the latest developments in animal husbandry and rehabilitation
techniques?
What support networks do you have?
What conservation benefits will be achieved by issuing this permit?
For a spotter catcher endorsed rehabilitation permit please supply the following details:
Please provide a current resume, including details of qualifications, and provide a statement addressing the
following selection criteria:
Required:
Demonstrated ability to handle a wide variety of wildlife, including macropods and reptiles;
Well developed wildlife identification skills;
Demonstrated ability to determine appropriate habitat through knowledge of fauna/flora
associations and habitat requirements.
Desirable:
Relevant experience in the fields of zoo-keeping, veterinary practices and/or wildlife
rehabilitation; and
Access to appropriate equipment to undertake spotter/catching activities.
8. What wildlife does the application refer to?
Birds
Mammals
Reptiles
Amphibians
Specific animal/s
Please note, if your application refers to flying-foxes or bats, it is your responsibility to ensure you are
vaccinated against Australian Bat Lyssavirus and that flying-foxes or micro-bats do not come into
contact with unvaccinated family members and friends.
Have you been vaccinated against Australian Bat Lyssavirus?
No
Yes, what date was your last vaccination or titre taken?
Not applicable
Page 5 of 8 • 1201026 Department of Environment and Heritage Protection
Application form
Rehabilitation permit
9. Referee reports
For new rehabilitation permit applicants and new spotter catcher endorsed rehabilitation permit applicants, give
details and attach written referee reports from two (2) independent people of professional standing to attest to
your competency.
Note: An employee of the Queensland Parks and Wildlife Service (QPWS) or the Department of Environment
and Heritage Protection (EHP) cannot be used as a referee.
Referee 1 Referee 2
Name: Name:
Current contact details: Current contact details:
Referee reports are attached
Yes No You cannot submit your application until written references are provided
(if applicable).
Note 1: You must provide two referees of professional standing in the relevant wildlife management field e.g.
wildlife care and rehabilitation, fauna surveys, environmental assessments. Suitable referees may be from the
veterinary, zoological or university fields. Referees should be able to attest to your knowledge, skills and
experience as outlined in the responses supplied within this application form. Referees must also outline their
own experience and/or competency, which they believe enables them to attest to your abilities.
Note 2: An experienced rehabilitator is a person with a minimum of five (5) years, ongoing demonstrated wildlife
rehabilitation experience.
Important: Upon expiry of an existing permit, when completing a new application applicants must
answer all questions and supply documentation and referee reports as detailed above in the following
manner:
1. for a rehabilitation permit:
once only, providing a permit is held continuously; for any breaks in licensing of 12 months or more
the applicant must provide current evidence as indicated above in Q.7 and Q 9; and
2. for a spotter catcher endorsed rehabilitation permit:
once only, providing a permit is held continuously; for any breaks in licensing of 12 months or more
the applicant must provide current evidence as indicated above in Q.7 and Q 9.
10. Applicant suitability
The permit may be granted if the applicant is an appropriate person to hold the permit i.e. if the applicant has
the ability to carry out activities under the authority in a competent and ethical way.
QUESTIONS DETAILS
Page 6 of 8 • 1201026 Department of Environment and Heritage Protection
Application form
Rehabilitation permit
1. During the past 10 years have you ever (in YES
Queensland or elsewhere) been found guilty
of any criminal offence or entered a plea of NO
guilty in a Court?
(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 YES
from another State, Territory or country that
was suspended and/or cancelled? NO
If yes, provide details about the permit, the
date it was suspended and/or cancelled and
reasons for suspension/cancellation.
11. 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
Please tick the appropriate box/es if you agree to have your details provided to the following organisations:
I agree to have my name and contact details provided to the Queensland Wildlife Rehabilitation Council (QWRC) for
the purpose of receiving information about QWRC and caring for wildlife.
For more information about QWRC visit: www.qwrc.org.au
I agree to have my name and contact details provided to the RSPCA Qld for the purpose of receiving information
about the RSPCA Qld 1300 ANIMAL Wildlife Hero Network.
For more information about RSPCA Qld visit: www.rspcaqld.org.au
Page 7 of 8 • 1201026 Department of Environment and Heritage Protection
Application form
Rehabilitation permit
12. Applicant checklist
Please return your completed application kit to:
Application form completed, signed and dated
Permit and Licence Management
Current membership list attached
Department of Environment and Heritage Protection
Supporting information attached (if applicable) GPO Box 2454
e.g. Brisbane
copy of qualifications Queensland 4001
history of caring experience Enquiries: 1300 130 372
details of rehabilitation facilities Facsimile: (07) 3896 3342
Email: palm@ehp.qld.gov.au
two referee reports (if applicable).
Code of Practice or guidelines may be obtained from the EHP website http://www.ehp.qld.gov.au or by
contacting EHP on 1300 130 372.
Page 8 of 8 • 1201026 Department of Environment and Heritage Protection
