Wellington Park Management Trust

PERMIT APPLICATION FORM To Apply for the ‘Taking’ of Native Flora (Issued under the Wellington Park Act 1993) Please fill in the form, then print and sign and submit as per details at the bottom of the page.

Applicant Surname: ...... Given Names: ...... On behalf of (Company Name): ...... Applicant’s Contact Address: ...... Phone Number: ...... Email: ...... Names and addresses of all those involved with the project who will also require a permit. For projects undertaken by large organisations, please provide name and title of the head of the organisation and the name of the organisation.

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Short title of project (for development proposals, quote the name (including author and date) of the relevant report. Include the proposal application number if known).

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Proposed start date ...... End date ......

Provide a brief description of the proposed activity and expert advice that has been provided (~150 words). (Where a document already exists which provides a description send a copy of it along with the application form instead). In all cases where destruction of native flora is proposed, any proposed mitigation measures must also be provided.

Notes  Please refer to ‘DPIPWE Guidelines for Permit Applications for the Taking of Native Flora’ to assist you in planning your activity and filling out this form.  For the purposes of this permit ‘take’ includes destroy or damage a plant and take destroy or damage any fruit, seed, product or other plant parts.

...... Plant species to be ‘taken’ (include scientific name) including the estimated number of plants to be ‘taken’ from, and the type and quantity of material required e.g. foliage, cuttings. (Attach a list if insufficient space).

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Describe in detail each ‘take’ location and/or attach a legible map showing each ‘take’ location, and describe the species to be ‘taken’ from each location.

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Provide a description of what the plant material taken will be used for, and the quantity and type of material to be used. E.g. One cutting of E. globulus for plant sample study.

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Location/s where the plant material taken will be used or lodged (eg glasshouse, herbarium)

...... Have you previously been issued with a permit to ‘Take’ Native Flora requiring, as one of the conditions, that a report be submitted? The report must be completed and submitted to the Trust before further permits will be issued.

Report submitted? Yes No

Signature of Applicant Date ......

Please Read Carefully: The Trust retains the authority to reject any permit application and also to apply conditions to any permit issued. Allow 2 weeks for processing of applications. A permit must also be sought from the Department of Primary Industries Water and Environment for any species listed on the Nature Conservation Act 2002 or the Threatened Species Protection Act 1995. Fees for permits may apply. Permit Applications can be Posted, Faxed or E-mailed to: Manager, Wellington Park Management Trust, GPO Box 503 Hobart TAS 7001; Ph: 03 6238 2176; Fax: 03 6234 9757; E-mail: [email protected]