CONSERVATION AND LAND MANAGEMENT REGULATIONS 2002 Aboriginal customary activities – written permission application form This form is to be completed if an Aboriginal person wishes to carry out a customary activity which requires the written permission of the Chief Executive Office under the Conservation and Land Management Regulations 2002. APPLICATION PROCESS Once a completed application has been lodged, the Department of Parks and Wildlife (DPaW) will aim to assess the proposed activities and grant a written permission within the shortest possible timeframe. This application may be posted, faxed, emailed or handed in person to the nearest District Office. It is recommended that you contact your local DPaW office and discuss your application with a staff member before completing this form. DPaW may refuse a written permission request if real or significant risks to the following are identified: public safety, the protection of flora and fauna and other values, uses or users of the reserve. APPLICANT DETAILS Name of applicant: (person(s)/ group/ body/ association written permission applies to) PROCESS Contact person’s name: Postal address of applicant: Telephone: Mobile: Fax: Email: Emergency contact name/ telephone number: DETAILS OF CUSTOMARY ACTIVITY Please describe the type and location where the proposed activities will be undertaken (Please list all reserves – terrestrial and marine, specific sites, tracks, roads and routes you intend to use). 2 Please describe any other information about the activities you wish to undertake, including if you intend to use firearms (e.g. types of animals intending to hunt, access through locked gates). Start date: Finish date: How many people will be undertaking these activities? c c No c Not csure c Do you expect these same activity(s) to be undertaken again? c c Yes c If the activity includes the use of firearms do you hold a current firearms licence? c Yes No To: The Director General of the Department of Parks and Wildlife I, (Full name, BLOCK LETTERS please) apply for written permission in order to undertake the activities specified in this application for Aboriginal customary purposes. I understand and agree that the written permission, if granted, will be subject to the provision of the Conservation and Land Management Act 1984, Wildlife Conservation Act 1950 and all relevant regulations. To the best of my knowledge the information provided within this application is true and correct and the activities will only be undertaken for genuine customary purposes in accordance with these Acts. I understand that there may be other legislation (eg, Bushfires Act, Firearms Act, water catchment bylaws) that I need to adhere to. I understand that I am responsible for the consequences of my actions when undertaking customary activities and will exercise all due care when doing so. Signed: Date: OTHER INFORMATION If appropriate please bring (or submit) a copy of your current firearms licence with this application. Applicants denied a written permission have a right of appeal. Applicants wishing to access disease risk areas need to apply separately for a permit under the Forest Management Regulations.