Application for Reimbursement of Treatment Costs for Mange Infected Wombats

Individual, Community Groups

Incurred costs from 13 March 2017 only.

Reimbursement requested (Excl. GST) / GST (only apply if you are registered for GST) / Totalreimbursement requested (Incl. GST)
$ / $ / $
Applicant details
Your name / start typing into the grey area
Name of Community Group(if applicable)
Property name
Property address
Postal address if different to above
Phone/mobile / E-mail
Are you applying as:
(please click to check the relevant box, or otherwise tick) / ☐ Not for profit organisation (incorporated)
☐ Individual / ☐ Other
If applying as a community group please provide a full list of member names (the list should be included as a schedule to this Application if additional space is required.
Do you hold the relevant permits required to treat wombat mange? Eg: Mange Management Incorporated APVMA sub-permit; Nature Conservation Act permit to take and or possess wombats. / ☐Yes (Please attach a copy of your permit/s) ☐No
Doyou, or your company have an ABN?
Please state your ABN (if applicable)
Are you/your company registered for GST? / ☐ Yes ☐ No
Program description
Briefly describe your program of treatment for mange infected wombats. Include: method of treatment applied, quantity of topical treatment purchased and used, the area the treatment program has covered (ha), number of wombats treated, feed requirements, and details on enclosures including materials used if constructed.
Please attach a map of the project area and photos and/or plans of enclosures if applicable. Your digital map and/or photos can be submitted either as a jpeg/bmp/pdf file attached to an email or inserted as a picture into your application below.
Please detail your/community groups past experience (including length of time) in the treatment of mange infected wombats.
Acquittal for Reimbursement of Costs (from 13 March 2017 only)
(consumables purchased directly associated with the cost of treatment for mange infected wombats. Please use GST inclusive figures if you are not registered for GST, ensuring total reimbursementdoes not exceed $3,000.
Item/s / Total ($)
TOTAL / =
Banking Details.
Account Name:
Account Number:
BSB:
Applicant declaration

In submitting this application I agree that:

☐ It is my responsibility to obtain any necessary permits.

☐ I have obtained permission from the land manager/s to undertake treatment activities in this area.

☐ Funds have been spent as outlined in this application.

☐ The Department of Primary Industries, Parks, Water and Environment may conduct site visits

☐ Details and images relating to the project may be included in Government media releases, newsletters, websites and other promotional or reporting media

☐ I will retain all relevant receipts for a period of two years.

☐I agree that I have read and understood the above terms (THIS BOX MUST BE TICKED)

Applicants Name or (electronic) Signature:

Date:

Please submit this application by e-mail

We prefer to receive electronicsubmissions, however you may post hardcopy applications to GPO Box 44 Hobart, TAS 7000.

For any queries in relation to this funding assistance proposal please email or call 61654305.