Application for an Herpetofauna Keeper Licence

Application for an Herpetofauna Keeper Licence

Application for a pet herpetofauna keeper’s licence

Licence covers keeping of any pet herpetofauna as declared by notice under Regulation 4(1).

Completed forms should be returned to:
Department of Parks and Wildlife
Locked Bag 30 Bentley Delivery Centre WA 6983
Or faxed to (08) 9219 8242 or emailed. / Further information on the licensing requirements is available from DPaW Wildlife Licensing Section
Phone: (08) 9219 9834
Email:

PLEASE ALLOW TWENTY (20) WORKING DAYS TO PROCESS COMPLETE AND CORRECT APPLICATIONS. INCOMPLETE APPLICATIONS WILL BE RETURNED FOR CORRECTION.

Applicant

Surname
Dr/Mr/Mrs/Miss/Ms / Other names
Address (residential)
Postcode
Address (postal)
Postcode
Address of premises for keeping pet herpetofauna
Postcode
Telephone / Fax
Mobile / Email
Date of birth / minimum age applies
/ / see page 2 / Applicant must provide proof of age (driver’s licence, passport, or other appropriate document).

DPaW OFFICE USE ONLY

APPROVAL
Application is / is not approved. / Date:
Signature / Position held:
Receipt # / Amount:
Licence # issued ______/ Licensing Officer:

Page 1 of 3Department of Environment and Conservation

Application for an Herpetofauna Keeper Licence

Personal experience and ability in keeping herpetofauna.
Attach written reference(s) supporting this application. These reference(s) should detail the applicant’s experience and ability in keeping herpetofauna.
Attached reference(s) from:
Brief description of facilities for keeping herpetofauna.
Detail any convictions against the Western Australian Wildlife Conservation Act and/or Regulations.

Applicant is required to provide:

1 proof of identity and age (driver’s licence, passport, or other appropriate document).

2 details of any relevant convictions in Australia in the past five (5) years. Relevant conviction means a wildlife related offence

Category 5 Herpetofauna only: The nominated premises where the Category 5 herpetofauna is to be kept will need to be inspected by a Wildlife Officer and the applicant interviewed. Please provide a contact daytime telephone number so that inspections can be arranged at a mutually convenient time.
Category of Licence and licence term being sought (tick only one):
Please attach a cheque or money order with completed application form, or complete credit details below:
Category 2 Licence for 1 yearFee $20 enclosed.
Category 2 Licence for 2 yearsFee $35 enclosed.minimum age 14 years
Category 2 Licence for 3 yearsFee $40 enclosed.
Category 3 Licence for 1 yearFee $40 enclosed.
Category 3 Licence for 2 yearsFee $75 enclosed.minimum age 18 years
Category 3 Licence for 3 yearsFee $100 enclosed.
Category 4 Licence for 1 yearFee $100 enclosed.
Category 4 Licence for 2 yearsFee $180 enclosed.minimum age 18 years
Category 4 Licence for 3 yearsFee $240 enclosed.
Category 5 Licence for 1 yearFee $300 enclosed.
Category 5 Licence for 2 yearsFee $500 enclosed.minimum age 18 years
Category 5 Licence for 3 yearsFee $650 enclosed.
Payment
Cheque enclosed – made payable to Department of Parks and Wildlife
Money order enclosed – made payable to Department of Parks and Wildlife
Payment made at DPaW office (refer to ‘Office Use Only’ section below)
Credit Card (complete ‘Credit Card Payment’ section below)
No responsibility will be taken for cash payments sent via mail.
CREDIT CARD PAYMENT (VISA & MASTERCARD ONLY) **Please print clearly**
               
Expiry Date: ____/____Name of Cardholder: ______
Signature: ______
SIGNATURE OF APPLICANT………………………………………DATE ………/…….…/20

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