Page 1 of 2

Section 120 National Parks & Wildlife Act 1974

APPLICATION FOR A NATIVE ANIMAL KEEPERS LICENCE

Follow these steps: 1. Only use this application form if you are a resident of NSW 2. Tick the box for the class(es) of licence you wish to apply for. You can apply for more than one class at a time 3. Follow the column down and write in the fee for each class you wish to apply for. Add up the fee amount for each class and write in the total fee. This will be the total amount you need to pay 4. Read the NOTES below and complete the rest of the application form 5. Post or fax the form to Wildlife Licensing and Management Unit, PO Box 1967, Hurstville NSW 1481. Applications cannot be lodged in person at the Hurstville office 6. Payment can ONLY be made by Credit Card, Cheque or Money Order (made payable to the Department of Environment, Climate Change and Water)

Basic Reptile Class

One year Two years
LICENCE TERMS AND FEES

Basic Bird Class $36.00 $63.00 $50.00

Basic Amphibian Class $36.00 $63.00 $50.00

Basic Mammal Class $36.00 $63.00 $50.00

$36.00 $63.00 $50.00

Two years pensioner discount Five years Five years pensioner discount Class fee $

$143.00 $115.00

$143.00 $115.00

$143.00 $115.00

$143.00 $115.00

$ TOTAL FEE PAYABLE

$ $

NOTES

An applicant must be over 10 years of age to apply for a Native Animal Keepers Licence. Applicants younger than 16 years of age must have their form signed by a legal parent/guardian. An applicant cannot possess or acquire any animal(s) before the granting of a Native Animal Keepers Licence If you are applying and believe you are eligible for a pensioner discount, you must provide a copy of both sides of your pension card Please allow twenty one (21) working days for the processing of your application If a licensee requests that their licence be cancelled within 30 days of being issued, a refund may be paid minus a maximum $40 administration fee. No refund is possible after 30 days has elapsed or if animals have already been acquired. A maximum penalty of $3,300 applies for supplying a false statement or providing misleading information in
an application for a licence or certificate by an applicant

APPLICATIONS/QUESTIONS MAY BE DIRECTED TO Wildlife Licensing and Management Unit, PO Box 1967 Hurstville NSW 1481

Phone: (02) 9585 6406

Fax:

(02) 9585 6401

Email: wildlife.licensing@environment.nsw.gov.au

Page 2 of 2

Use BLOCK LETTERS

Mr/ Mrs/ Ms/ Miss/ Dr/ Master Given name: Family name: Date of birth:
dd dd dd dd dd dd mm mm mm mm mm mm y yyy yy y yyy yy y yyy yy y yyy yy

Middle name:

Postal address: APPLICANT DETAILS

State: Premises where the animal(s) will be kept:

Postcode:

State: Home phone: E-mail: Preferred contact method: phone mail email Day time phone number:

Postcode:

Mobile no: Fax no:

Preferred correspondence method:

mail

email

PARENT or GUARDIAN

An applicant must be over 10 years of age to apply for a Native Animal Keepers Licence. Applicants younger than 16 years of age must have their form signed by a legal parent/guardian (detailed below) who resides with the applicant and will be legally responsible for the activities of the licensed person.
Mr / Mrs / Ms Miss / Dr Parent or guardian date of birth:
dd dd dd dd dd dd mm mm mm mm mm mm yyy y yy yyy y yy

Name of parent or guardian:

Day time phone number:

Fax no:

Relationship to applicant:

yyy y yy

yyy y yy

PAYMENT DETAILS

Enter your payment details here if you are paying by Credit Card. You may also pay by cheque or money order (made payable to the Department of Environment, Climate Change and Water). If you are applying on the basis of a pensioner discount, you must provide a copy of both sides of your pension card.
MasterCard Card number Name on card: Card holders signature: Visa Card expiry date:
mm mm mm mm mm mm yyy y yy yyy y yy

Amount:

I herby apply for a Native Animal Keepers Licence under section 120 of the National Parks and Wildlife Act 1974 for the class(s) indicated by me to acquire and hold native animals as listed in the NSW Native Animal Keepers Species List or as otherwise published by the Department and:
DECLARATION

I declare that the premises nominated above as the place where all my animal(s) will be kept is not used for the conduct of any commercial activity. I declare that the animal(s) held under the licence will not be placed on public display or exhibit. I declare that I do not already have any protected native animal(s) in my possession and will not acquire any protected native animal(s) prior to the granting of a Native Animal Keepers Licence to me. I have read and agree to follow the conditions of a Native Animal Keepers Licence as displayed on the Departments web site at www.environment.nsw.gov.au I declare that all the information provided by me in this application is true and correct.
Date:
dd dd dd dd dd dd mm mm mm mm mm mm yyy y yy yyy y yy yyy y yy yyy y yy

Applicants signature: Parent/guardians signature (who is named above): OFFICE USE ONLY Area Office: Date of Receipt:

Receipt No: Amount Paid:

The National Parks and Wildlife Service is part of the Department of Environment, Climate Change and Water (NSW) ABN 30 841 387 271