University of Canberra

COMMITTEE FOR ETHICS IN ANIMAL EXPERIMENTATION APPLICATION FOR AUTHORISATION TO CONDUCT EXPERIMENTS USING ANIMALS (as required under the ACT Animal Welfare Act 1992)

Applicants name (incl. title):

Reason for authorisation: PhD: Hons: Other: (X) (X) (Explain)

Phone number: Email:

Institution: (University of Canberra or other)

Full address:

Name of research program(s) you will be associated with:

Formal qualifications including institution and date:

Animal Ethics test was Highest grade achieved: undertaken on:

EXPERIENCE Please describe your specific experience in animal handling and animal experimentation, with an indication of the periods/dates of that experience. If the applicant has no, or limited experience in animal handling and/or the techniques or procedures to be used to the next 3 years, please include details of any training that will be undertaken to develop the relevant skills and experience.

If you have a refereed publication(s) describing experiments that you have undertaken using animals, please cite reference(s).

If you do not have any applications then please state ‘none’.

Signature: Date:

Investigators authorised to conduct experiments using animals for research or teaching will receive an identity card which should be available for inspection on request by a member of the Ethics Committee or an authorised ACT inspector.

(Revised December 2008)