Application for an Wildlife Display Authority - other than residence
Application for a licence to keep fauna for educational or public purposes
Licence covers the display of fauna as mobile displays at locations other than their place of residence.
Class in relation to animalsmeans any group or grouping of animals; ie. Mammals, reptiles, avian fauna.
PLEASE ALLOW TWENTY (20) WORKING DAYS TO PROCESS COMPLETE AND CORRECT APPLICATIONS. INCOMPLETE APPLICATIONS WILL BE RETURNED FOR CORRECTION.
PLEASE ENSURE THAT THE ASSOCIATED GUIDELINES DOCUMENT IS READ BEFORE COMPLETING THIS APPLICATION FORM AND THAT ALL NECESSARY DOCUMENTS ARE INCLUDED WITH APPLICATION.
Completed forms should be returned to:Department of Parks and Wildlife
Locked Bag 30 Bentley Delivery CentreWA 6983
Or faxed to (08) 9219 8242or emailed. / Further information on the licensing requirements is available from DPaW Wildlife Licensing Section
Phone: (08) 92199833
Email:
Applicant
SurnameDr/Mr/Mrs/Miss/Ms / Other names
Address (residential)
Postcode
Address (postal)
Postcode
Phone / Fax / Email
Mobile / Date of birth
Applicant is required to provide:
1 proof of identity and age (driver’s licence, passport, or other appropriate document).
2 details of any relevant convictions in Australia in the past five (5) years.Relevant conviction means a wildlife related offence
3 a written plan detailing educational program as per attached guidelines
4 details of history and suitability of specific animals for display (Note some animals are unsuitable for display based on their appearance or naturefor example, nervous disposition)
5 separate application to the department for additional animals to be added to the licence and these animals must fit the criteria of the guidelines.
Note:Licence conditions include the requirement for returns, an itinerary of intended displays and an annual report summarising the results of the educational program, including the number of schools attended, fauna used and any feedback.
Page 1 of 5
Application for an Wildlife Display Authority - other than residence
Proposed name of your operationBusiness or Company Names (if applicable)
Address where fauna will be kept
Postcode
List all other licences issued under the Wildlife Conservation Act 1950 held by you (including licence number):
List any licence(s) issued under the Agriculture and Related Resources Act1976 held by you (including licence number):
Are you involved in any business association with the holder of any other licence issued under the Wildlife Conservation Act 1950? If Yes, detail the relationship and involvement.
Detail any convictions against the Western Australian Wildlife Conservation Act and/or Regulations.
Fauna to which application relates
(If insufficient space please attach list.)
Common name / Numbers to be displayedFrom whom / where will the fauna be obtained?
State your experience in keeping and caring for these fauna (or other animals)
What type, style and number of cages/enclosures (travelling) are to be used?
Type
Style
Number cages
Number enclosures
Applicant is required to note:
No responsibility will be taken for cash payments sent via mail. Please either include a cheque or postal money order made payable to Department of Parks and Wildlife with your application; OR complete the credit card payment details as below; OR attend the Wildlife Licensing Section at 17Dick Perry Avenue, Kensington to process your application payment.
Category of Licence and licence term being sought (tick only one):Wildlife Displays Licence for 1 classFee $50enclosed.
Wildlife Displays Licence for 2 classes (maximum)Fee $100enclosed.
PLEASE NOTE: No responsibility will be accepted by DPaW for any cash payments made via post.
CREDIT CARD PAYMENT (VISA & MASTERCARD ONLY) **Please print clearly**
Name of Cardholder: ______Expiry Date:____/____
Signature of Cardholder: ______
Signature of applicant………………………………………Date………/…….…/……
DPaW OFFICE USE ONLYAPPROVALLicence # issued ______/ Licensing Officer:
Page 1 of 3