DEPARTMENT OF ECONOMIC DEVELOPMENT,
JOBS, TRANSPORT & RESOURCESFisheries Victoria
Fisheries Act 1995
FORM 07 – Application for a General Permit for the purpose of research
Applicant Details
Applicants full name
Date of birth
Organisation name (if applicable)
Address (cannot be a post office)
Postaladdress
Home phone number Fax number
Work phone number Mobile phone number
Email address
Project details
Project Title
Objectives of research (use additional pages if required)
Who will be conducting the collection of specimens?
Fish species and numbers you intend to collect – both
scientific and common names (use additional pages if required)
Duration of time that the permit is required.
From: To:
Is your proposed worksubject to approval by an ethics committee?
Please tick appropriate box:
No Yes
(If yes, please attach completed application for ethics committee approval)
If you are a student/s, please provide the following information:
Undergraduate Post Graduate
Name and contact details of Supervisor
Name and faculty of Educational Institution
Gear and Location
Proposed methods of collection (Please tick more than one box where applicable)
Trap
/ /Mesh net
/Seine Net
/ /Line
/Electrofishing
/ /Hand Collection
/Other
/ /If other, please specify
Provide details of the gear proposed. e.g. mesh size and length of nets to be used, dimensions and descriptions of traps etc.
Where risks to non-target species may be present, you should identify these risks and indicate how they will be mitigated.(Use additional pages if required)
Provide details of experience with the equipment to be used in the collection of specimens? (eg. experience in the use of fyke nets, electrofishing equipment etc.)
Proposed locations for collection. Please provide a map and sufficient detail to identify specific locations.
(Use additional pages if required)
Checklist
Have you?
Read the attached Applicant Information Sheet
Completed the attached Fit & Proper Form
Included the payment of fee (refer to Applicant Information Sheet)
Declaration
By signing this document you certify that the information contained in this application is true, correct and complete, and that you have read and understood the information sheet for applicants.
Failure to include any material matter with the result that the information provided is misleading, or providing false or misleading information in a material detail may result in prosecution under section 119A, 119B or 148(7) of the Fisheries Act 1995.
Signature Dated
DEPARTMENT OF ECONOMIC DEVELOPMENT,
JOBS, TRANSPORT & RESOURCESFisheries Victoria
Fisheries Act 1995
Fisheries Act 1995 - Fit and Proper Person Information Form
This form must be completed by:
* all individuals applying for the issue of a permit
* each director of a company or co-operative applying for the issue of a permit
* each person who is proposed to be nominated as an authorised person
Please provide FULL details of all findings of guilt by a court* recorded against you, or infringement notices** issued to you, in any State, Territory or Commonwealth jurisdiction. Include date, details of offence & penalty imposed and, for court matters, include hearing date and the court in which the matter proceeded. If insufficient space, attach a separate sheet. If you have no findings of guilt or infringement notices write the words “Nil” below.
*Findings of guilt by a court are NOT limited to fisheries offences.
**infringement notice are limited to fisheries offences under the Fisheries Act 1995, or Fisheries Regulations or equivalent laws in the Commonwealth, or another State or Territory.
Certification and Consent
I certify that the information contained in this application is true and correct.
I agree to notify the Department ofEconomic Development, Jobs, Transport & Resources in writing as soon as I become aware of a change in my circumstances.
I consent to the Department of Economic Development, Jobs, Transport & Resources seeking copies of information or records held by any federal or state fisheries, quarantine, environmental or business licensing or registration agency for the purpose of verifying the information provided in this form and determining the application.
I acknowledge that a copy of this form will be retained by the Fisheries Division of the Department of Economic Development, Jobs, Transport & Resources, and that this form (along with any documentation relating to my compliance with the Act) may be reviewed by the Department of Economic Development, Jobs, Transport & Resources’ Fisheries Division and the Secretary in the future for the purposes of considering whether to issue, renew or transfer licences or permits under the Fisheries Act 1995 to me or to a company or cooperative of which I am a director.
Full name of person making this declaration Date of birth
Signature of person making this declaration Dated