FORM TITLE

Applicant details

First name / Last name
Property address / State
Postcode
Postal address / State
Postcode
Phone / Mobile / Fax
Email / UHF
ABN / Are you registered for GST? Yes No

Privacy and confidentiality

If you wish your application or personal details to remain confidential, you can request this. Please show your preference in the space below. The NSW Office of Water may be required by law to release copies of applications received to third parties. This will be determined according to the Government Information (Public Access) Act 2009.
I would like my registration of interest to remain confidential / Yes No
I would like my personal details to remain confidential / Yes No

Group / Property details and sketch plans

Please attach plans showing all property boundaries, areas, any existing water distribution systems, and full details of all landholders obtaining water from this water supply.
Group / Property name / Area / ha
Tenure / Average stocking rate
Are you part of a joint water supply Scheme, Authority, Trust or District? If yes, please provide details / Yes No
Details
Have any surveys or designs been prepared for the proposed works? If yes, please provide details / Yes No
Details
Do you agree to complete all works within twelve months? / Yes No

Existing water supply – Only High Security Stock and Domestic licences are eligible for this project

Name of the current water source (Creek, River, etc.)
Water access licence number / Volume on licence / ML
Purpose (stock, domestic, other?) / Other – please specify
Work approval number for your pump
I hereby apply to participate in the Basin Pipe program and declare that the information supplied is true and correct.
Applicant’s name / Date

Return this form by: More information

Email (as an attachment)
Post NSW Office of Water, PO Box 463, Inverell NSW 2360
Fax 02 6721 9898 / www.water.nsw.gov.au/mdb

Free call 1800 353 104

Privacy: Information collected will not be given to any other third party except where required by law. All information provided will be held by the NSW Office of Water and will be managed in accordance with provisions under the Privacy and Personal Information Protection Act 1998. Information collected in this form will be stored securely and used only for the purposes for which it has been collected. See our full privacy policy at www.water.nsw.gov.au/About-us/Privacy

Office Use Only / Entered by / Date

Jobtrack 12270_ROI

Page 2 of 1