Northern Permit Application Form Issued under the Aboriginal Land Act (NT) 1980 § Please answer all questions unless stated otherwise (if provided space is insufficient an attachment is acceptable). § Permits will not be processed without the relevant information. § Processing the application may take up to 10 working days. Note: There are application forms for research and media/filming purposes and the processing times is much longer.

I apply for permission to enter and remain on Aboriginal land or sea adjoining Aboriginal Land. 1. Principal Applicant’s Name: (including others 11. Accommodation details: *(please refer below) accompanying the applicant) Community Resident Invited Visitor

Tourist Commercial Other

2. Principal Applicant’s Address : 12. Areas to be entered: (please provide exact locations and dates) Street: ______Destination 1: Entry: / / Exit: / / Suburb/Town: ______Destination 2:

Entry: / / Exit: / / 3. Postal Address: 13. Method of Transport: Vehicle Vessel Aircraft Make & Model: 4. Phone Business Hours:

Mobile Number: ______Reg. No: State: ______5. Email Address: ______Colour: ______

6. Please supply specific details for the purpose of 14. Indicate where permit will be collected from: entry: (i.e. type of activities) Darwin Nhulunbuy Timber Creek Jabiru Katherine

7. Are you applying for a WORK permit? Yes continue with number 8 15. Proposed date when permit will be collected: No go to number 11 / /

8. Organisation / Company: Applicant`s Signature: Date Signed: / /

9. Position held:

10. Government Contract No: ______Traditional Owner`s Approval: Yes No nO Permit Delegate`s Signature:

NLC Mining or s19 Agreement No: 1. 2.

*Point 11. For verification purposes, please provide accommodation details, contact name & number of who you are visiting in the community. For all permit enquiries, please contact the relevant office or email [email protected] Darwin (Head Office) Jabiru (West Arnhem) Katherine (South Region) Nhulunbuy (East Arnhem) PO Box 1222 PO Box 18 PO Box 396 PO Box 820 45 Mitchell Street Unit 3 Government Building 5/29 Katherine Terrace Endeavour Square Darwin NT 0801 Jabiru NT 0886 Katherine NT 0851 Nhulunbuy NT 0881 Phone: (08) 8920 5100 Phone: (08) 8938 3000 Phone: (08) 8971 9899 Phone: (08) 8986 8500 Fax: (08) 8945 26 33 Fax: (08) 8979 2650 Fax: (08) 8972 2190 Fax: (08) 8987 1334 Last Updated August 2015

COVID-19 TRAVEL DECLARATION

Due to the ongoing COVID–19 Pandemic, all persons seeking permission to access Aboriginal land/communities must complete a Travel Declaration. The information to be provided in this form is to assist the NLC in deciding whether to grant a permit under the Aboriginal Land Act 1978 (NT).

I, ______(name)

of ______(address) request permission to enter the designated area and to travel to

______(Aboriginal land/community) for the purposes of undertaking the following activity:

______(description of activity)

Photo/scan of my licence or photo ID is attached:

Have you or any other person listed in this permit application travelled outside of Australia (overseas) and/or entered into the (from overseas or interstate) in the last 14 days?

Yes No

If you have ticked YES, provide details of travel and advise what quarantine arrangements have been made by you, or made for you.

______

______

______

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By accepting this permit you accept all additional conditions and obligations set out on page 3 of this document:

NAME

SIGNATURE

(DETAILS TO BE ENTERED BY NLC STAFF) DATES (valid from and to date) (DETAILS TO BE ENTERED BY NLC STAFF) PERMIT ID#

Please return to [email protected].

Office Use Only:

Signed and authorised by:

Permit Delegate (DATE)

Additional Permit Obligations

1. The permit holder must at all times comply with any relevant directions from the Chief Health Officer and SecureNT. 2. If the permit holder begins to present symptoms consistent with the coronavirus disease (COVID- 19) (Coronavirus) (i.e. sore throat, headaches and fever): i) the permit holder must immediately notify the relevant Permit Officer at the Northern Land Council by emailing [email protected]; ii) the permit holder must not travel to or remain on Aboriginal land; iii) the permit is immediately revoked; iv) if the permit holder is already on Aboriginal Land, they must immediately notify the Department of Health - Pandemic Clinic on 8922 8044 and take all necessary and reasonable steps to leave Aboriginal land with minimal interaction with any other persons, and keep a record of all persons they have interacted with and places they visited; and v) the permit holder must not approach any local remote community health care centre without first contacting the centre via telephone and speaking to a health professional. 3. If the permit holder comes into contact with a person who has or is suspected to have Coronavirus: i) the permit holder must immediately notify the relevant Permit Officer at the Northern Land Council; ii) the permit holder must not travel to or remain on Aboriginal land; iii) this permit is immediately revoked; iv) if the permit holder is already on Aboriginal Land, they must immediately notify the Department of Health - Pandemic Clinic on 8922 8044 and take all necessary and reasonable steps to leave Aboriginal land with minimal interaction with any other persons, and keep a record of all persons they have interacted with and places they visited; and v) the permit holder must not approach any local remote community health care centre without first contacting the centre via telephone and speaking to a health professional. 4. If a permit holder travels overseas or outside the Northern Territory, their permit is immediately revoked and they must immediately notify the relevant Permit Officer at the Northern Land Council. 5. When travelling on Aboriginal land, the permit holder must: i) travel to their destination using the most direct and efficient route; and ii) not make any additional or unnecessary stops. 6. When on Aboriginal land, the permit holder: i) must not approach community members or allow themselves to come within two metres of a community member; ii) wipe down the areas in which any work is undertaken with an appropriate disinfectant before commencing and after concluding the works; and iii) at all times carry hand sanitiser and regularly use it. 7. If a permit holder is staying overnight on Aboriginal Land, the permit holder must, except in cases of emergencies: i) if staying in accommodation, at all times confine themselves to their room or accommodation, except when undertaking the works or at meal times; and ii) if camping, ensure that their campsite is outside of town and not allow community members to enter their campsite and remove all rubbish, waste, camping equipment and any other objects when they leave the camp site and remain at their campsite, except when undertaking the works or at meal times. 8. A permit holder is prohibited from entering any building or structure on Aboriginal land, with the following exceptions: i) the works require a permit holder to be in a building or structure; ii) in the case of an emergency; iii) if the building or structure is the permit holder’s accommodation; or iv) if the building or structure is a place where fuel or food may be purchased and must wear an appropriate face mask or covering when entering those buildings or structures.

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