Permit - Application

INLAND FISHERIES SERVICE (Constituted under the Inland Fisheries Act 1995)

17 Back River Road New Norfolk TAS 7140 PO BOX 575, New Norfolk TAS 7140 Telephone: (03) 6261 8050 Facsimile: (03) 6261 8051 Email: [email protected]

APPLICATION FOR AN EXEMPTION PERMIT I wish to make an application for an exemption permit under Section 170 of the Inland Fisheries Act 1995.

Name:

....................................................................................................... (Surname)

(Given Names)

Company Name:

.......................................................................................................

Contact Address:

.......................................................................................................

Mailing Address:

.......................................................................................................

Phone Number:

Work

Fax Number:

(..........) ................................

Date of Birth:

.............................................

(..........) .....................

After Hours

(..........) .........

Please tick one or more of the appropriate boxes: Proposed activity –

1.

Importation into Tasmania

2.

Collection of freshwater fish

3. 4.

Retention of freshwater fish

5.

Culture

❏ ❏ ❏ ❏ ❏

Fishing

Proposed activity to be undertaken for the purpose of – (a)

Scientific research

(b)

Promotion of fishing

(c)

Development of fisheries

(d)

Development of fishing technology

(e)

Educational and community awareness programs

(f)

Fish stock depletion or enhancement

(g)

Collection, keeping, breeding, hatching or cultivating of freshwater fish

(h)

Sport or recreational purposes (person with a disability only)

(i)

Other (please explain)

❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏

eg. For use as crayfishing bait Has a permit for this project been issued for the same purpose previously?

Yes/No

Permit No: .......................

PTO

Details (i) Target Species

Name of Water

Locality Details (map references)

National Park or Number of Conservation Area? Each Species to be Taken

(ii)

Requested duration of permit:

(iii)

Will there be people assisting you in your proposed activity? Please list (if insufficient space, attach list to application):.......................................................................…………..........………... ......................................................................................................................……………….........

(iv)

Method to be used to obtain the proposed species (if insufficient space, provide a detailed description in attached summary): ……………………………………………………………… ….

(v)

Is approval required from animal ethics committee? Yes/No. (If Yes please submit a copy of the approval with this application.

(vi)

Have you ever been convicted of a fisheries offence or do you currently have charges for a fisheries offence pending against you? Yes/No (If yes, please provide details): ………………… …………………………………………………...................................……….....………………… ……………………………………………………………………………………. ........................................................................................................................……………….......

(vii)

Other relevant information: …………………………………………………………………………

Items to be lodged with application 1. The prescribed permit application fee being $128.00 2. Other approvals (eg Animal Ethics Committee, Parks and Wildlife Service, Threatened Species Section DPIW). 3. Brief summary of proposed activity (include details on proposal, collection and/or retention methods, culture methods). Declaration I hereby declare that all information provided in this application is true and correct. I understand fully the regulations pertaining to the activity to which this permit applies. Signature of Applicant: ................................................

Date: ....................................

Office Use Only Yes

No

Application fee paid Appropriate approvals presented Application approved

Signed (Director) : ................................................ Please Note:

Date: ....................................

The information on this application will be given to Parks and Wildlife Service if a permit is required to collect freshwater fish from within a National Park or Conservation Area.