SCHEDULE 6

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SCHEDULE 6 Powered By Docstoc
					                                 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 of practice 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 Department of Primary Industries 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:
                                                                                                                                            AEC
                Floor
  Room                             Building                                          Street address                                      inspection
               number
                                                                                                                                            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 BAW within the previous 3 years must be
inspected by the Bureau after AEC approval and prior to being listed on the licence.

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 PART D. VARIATION OF ANIMAL ETHICS COMMITTEE DETAILS

 Name Animal Ethics Committee: ……………………………………...……………………………

  [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 Department of Primary Industries 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.]
  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

                                                     Category or role (include chair category if they
Title      Name              Surname                                                                                           Voting?             New?
                                                                    function in one)




  List proposed committee members including qualifications for the appropriate category (Australian
  code of practice for the care and use of animals for scientific purposes reference S2.2.2), adding
  additional tables and lines as necessary. Examples of acceptable qualifications are provided.

  Category A (Veterinarian member)

  Title: …………….. ; Given name: ………..…………....; Surname: ……………..………..............

  Date of appointment: ….…….…… 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

         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.

  ……………………………………………………...………..…………………………...…………

  ……………………………………………………...………..…………………………...…………
   [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 Department of Primary Industries 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.]
……………………………………………………...………..…………………………...…………

Category B (Researcher/teacher member)

Title: …………. ; Given name: …………….…………....; Surname: ……………..………..............

Date of appointment: ….…….……… 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: ……………....……...............

Date of appointment: ….….……… 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.

……………………………………………………...………..…………………….……...…………

……………………………………………………...………..…………………………....…………

        Provide a statement that the proposed member is not involved in the care and use of animals
         for scientific purposes

……………………………………………………...………..…………………………...…………

……………………………………………………...………..…………………………...…………

 [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 Department of Primary Industries 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 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: …………..…………...............

Date of appointment: ….….……… 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): ……………………………………

       Provide a brief description of the role of the member.

……………………………………………………...………..…..………………………...…………

……………………………………………………...………..…………………………...…………
 [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 Department of Primary Industries 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.]
                 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 2006, 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 2004 onwards

Category C (Animal welfare member)

 demonstrated commitment to, and established experience in furthering the welfare of animals -
From 2003 to 2006 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
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.

 [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 Department of Primary Industries 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.]
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

Return to Contents

Attach a copy of revised AEC terms of reference (TOR). The TOR must provide for the following
     points (Australian Code reference S2.2.1.). If procedures are not detailed in the TOR, they
     must be laid-down in documents referred to in the TOR:
    approve guidelines for the care of animals that are bred, held and used for scientific purposes
     on behalf of the institution;
    monitor the acquisition, transportation, production, housing, care, use and fate of animals; [if
     AEC is based outside Victoria, attention must given to how it will monitor animal welfare in
     Victoria]
    recommend to the institution any measures needed to ensure that the standards of the Code
     are maintained;
    describe how members are appointed, re-appointed, or retired, according to procedures
     developed by the institution in consultation with the AEC;
    require that all members declare any conflict of interest;
    deal with situations in which a conflict of interest arises;
    examine and approve, approve subject to modification, or reject written proposals relevant to
     the use of animals for scientific purposes;
    approve only those studies for which animals are essential and justified and which conform to
     the requirements of the Code. This should take into consideration factors including ethics, the
     impact on the animal or animals and the anticipated scientific or educational value;
    withdraw approval for any project;
    authorise the emergency treatment or euthanasia of any animal;
    examine and comment on all institutional plans and policies that may affect the welfare of
     animals used for scientific purposes;
    maintain a record of proposals and projects;
    comply with the reporting requirements of the institution and the Code; and
    perform all other duties required by the Code.

Type date of effect of change of TOR: …………………………………..

Return to Contents

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: …………………………………...

Return to Contents

 [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 Department of Primary Industries 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.]
FORWARDING DETAILS
Forward signed Parts of this form by mail to:

Licensing and Communications Officer,
Bureau of Animal Welfare,
475 Mickleham Rd,
ATTWOOD, VICTORIA 3049

Forward unsigned Parts of this form by email, fax or mail to
 alan.fried@dpi.vic.gov.au
 (03) 9217 4331
 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 Department of Primary Industries 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.
Return to form.

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.
Return to form

Premises
Premises that may be licensed are those that the licence holder legally occupies (owns, leases or
holds under formal agreement).
Return to form

AEC monitoring of interstate activities
The Australian Code of Practice for the care and use of animals for scientific purposes states that
AEC members should inspect all animal housing and laboratory areas regularly and record their
findings (Section 2.2.29). 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.
Return to form

Further information
Bureau of Animal Welfare
Victorian Department of Primary Industries

animal.welfare@dpi.vic.gov.au
(03) 9217 4425

Webpage: www.dpi.vic.gov.au/animalwelfare/procedures




 [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 Department of Primary Industries 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.]