Application form

Application to prepare a voluntary environmental impact statement

Environmental Protection Act 1994

Application to prepare a voluntary environmental impact statement

This is the approved form that is to be usedunder sections 70 and 71 of the Environmental Protection Act 1994 (EP Act) to apply for approval to prepare a voluntary environmental impact statement (EIS).

An EIS is a document that assesses the potential adverse and beneficial impacts (environmental, economic and social) of the project, proposes measures to manage potential impacts, looks at alternatives to the project, and provides information to decision-makers.

Guidelines and further information about the EIS process can be found at

If you would like to have a pre-lodgement meeting, please fill out and lodge the form Application for a Pre-Design/Pre-Lodgement Meeting (EM1125), prior to lodging this application.

Checklist for making an application

You must complete this checklist before you continue with the application form.

Checklist questions / Guidance
Have you made an environmental authority application where written notification in the information stage has been received that an EIS must be prepared under section 143 of the EPAct? / YES
NO / If yes, an application cannot be made as the project does not meet the criteria for projects that may be approved for an EIS.
Do both the below criteria apply to the project?
  • An EIS (or similar document) for the project is required to be prepared under another State Act; and
  • The other State Act does not allow the EIS to be prepared under the EP Act.
/ YES
NO / If yes, an application cannot be made as the project does not meet the criteria for projects that may be approved for an EIS.
Does the Commonwealth Environment Protection and Biodiversity Conservation Act 1999require theproject to be assessed under chapter 4, part 8 of that Act (i.e. to be a controlled action) and the EIS process has not been decided as anaccredited process under that Act? / YES
NO / If yes, an application cannot be made as the project does not meet the criteria for projects that may be approved for an EIS.
GUIDE /

Applicant details

The ‘applicant’ is the proponent for the project.
The ‘proponent’ is a registered legal entity intending to carry out the activity and in whose name the applicable permits or licences are to be issued.
Enter name and title of the appointed signatory (e.g. John Jones, Managing Director).
All bodies registered under corporations law, will have an Australian Business Number (ABN) or Australian Company Number (ACN).
Please make sure the contact details provided are those by which you can be contacted on a daily basis.
If more space is required for any responses, please attach additional information as a separate page.
If you require assistance in answering any part of this form, or have any questions about your application please contact Permit and Licence Management. Contact details are at the end of this form.
Where the project is a joint venture, list all joint venture partners in Attachment 1. / 1.Proponentdetails
PROPONENT’SNAME(S) (PRINT FULL NAME)
RESPONSIBLE PERSON/APPOINTED SIGNATORY
ABN/ACN
FULL RESIDENTIAL ADDRESS OR REGISTERED BUSINESS ADDRESS (NOT A POST OFFICE BOX ADDRESS)
FULL POSTAL ADDRESS (IF DIFFERENT FROM ABOVE)
If there is an agent acting on behalf of the proponent or joint venture parties, provide details in this section. An agent could be a consultant or a contact for the applicant(s). / 2.Agent for proponent
INDIVIDUAL OR BUSINESS NAME (INCLUDE TRADING NAME IF RELEVANT)
RESIDENTIAL ADDRESS OR REGISTERED BUSINESS ADDRESS (NOT A POST OFFICE BOX ADDRESS)
POSTAL ADDRESS (IF DIFFERENT FROM ABOVE)
CONTACT PERSON
PHONE / FACSIMILE
EMAIL
A proponent may voluntarily prepare an EIS for a project if it is believed by the proponent to be appropriate to do so.
This application is required to be supported by enough information to allow the chief executive of the EP Act to decide whether an EIS is appropriate for the project.
Examples of ancillary activities include: accommodation for workers, transport of product, waste management, power supply, proposed methods for waste management (e.g. tailings dam requirements).
Operational land is the land on which the project is to be carried out.
This application is required to be supported by enough documents or information to establish that the proponent may enter land to which the project relates to carry out any necessary studies for the EIS, e.g. evidence of a current mining tenement.
Note: the definition of ‘person’ (Chapter 3, EP Act) includes a body of persons, whether incorporated or unincorporated.
Environmentally relevant activities (ERAs) are listed in Schedule 2 of the Environmental Protection Regulation 2008. / 3.Supporting information to be attached must include, but not be limited to, the following information. Please tick the supporting information that you have attached to this application:
a description of the project, including total area proposed to be disturbed and proposed ancillary activities
locality map(s)
site plan(s)
a description of the operational land
documentary evidence that the proponent may enter land to which the project relates to carry out any necessary studies for the EIS
tenement details
a list stating the name and address of the affected and interested persons[1] for the project
a statement of how the proponent proposes to consultwith the interested and affected persons
a list of environmentally relevant activities to occur as part of the project for which an aggregate environmental score is stated. Include an illustration of the location of these activities on a site map
the proposed source of water for the project, including approximate volumes
proposed post resource activity land use, including any non-beneficial land use that will remain
other, where relevant (please specify):
The first step towards payment is to calculate the fees payable. Information on these fees can be located in the information sheets Fees for Permits for Environmentally Relevant Activities (ERAs) (EM33) and Summary of Annual Fees for Environmentally Relevant Activities (ERAs) (EM389), available at or through Permit and Licence Management (contact details are provided at the end of this form) for the current fee.
To pay by credit card you will need to provide contact details so you can be contacted for your credit card payment to be made over the phone. / 4.Payment of fees
The application fee is: / $
You may pay your fee via cheque, money order or credit card.
Select the payment method below:
Payment by cheque or money order made payable to the Department of Environment and Heritage Protection (attached).
Please contact me (the appointed signatory) for credit card payment:
Phone number:
Where there is more than one applicant (i.e. joint venture partners), this declaration is to be signed by all partners. Where the applicant is a company, this form is to be signed by the appointed signatory.
Privacy statement
The Department of Environment and Heritage Protection (the department) is committed to protecting the privacy, accuracy and security of your personal information in accordance with the Information Privacy Act 2009. The department is collecting your personal information in accordance with sections 70 and 71 of the Environmental Protection Act 1994in order to process your application. The information will only be accessed by authorised employees within the department. Your information will not be given to any other person or agency unless you have given us permission or we are authorised or required by law. All information supplied on this form may be disclosed publicly in accordance with the Right to Information Act 2009 and Evidence Act 1977. For queries about privacy matters email: or telephone: (07) 3330 5436. / 5.Declaration
Note: If you have not told the truth in this application you may be prosecuted.
I declare that:
  • I am the proponentor an authorised signatory for the proponent.
  • The information provided is true and correct to the best of my knowledge. I understand that it is an offence under section 480 of the Environmental Protection Act 1994 to give to the administering authority or an authorised person a document containing information that I know is false, misleading or incomplete in a material particular
  • I understand that failure to provide sufficient information may result in the application being refused
  • I understand that all information supplied on or with this application form may be disclosed publicly in accordance with the Right to Information Act 2009 and the Evidence Act 1977.
PROPONENT’S NAME
RESPONSIBLE PERSON/APPOINTED SIGNATORY’S SIGNATURE
POSITION OF SIGNATORY / DATE
NAME OF JOINT VENTURE PARTY(IF APPLICABLE) / JOINT APPLICANT’S SIGNATURE (IF APPLICABLE)
NAME OF JOINT VENTURE PARTY (IF APPLICABLE) / JOINT APPLICANT’S SIGNATURE (IF APPLICABLE)
Proponent’schecklist
Application form has been signed and all questions completed.
All requested supporting information is attached.
Attachment 1: Joint applicant information is complete (if applicable)
Fees paid or enclosed.
Further information
The latest version of this publication and other publications referenced in this document can be found at using the relevant publication number (EM1895)for this form as a search term or by contacting Permit and Licence Management. /

Please submit your completed application kit to:

Post:
Permit and Licence Management
Department of Environment and Heritage Protection
GPO Box 2454
BRISBANE QLD 4001 / Courier or hand delivery:
Permit and Licence Management
Department of Environment and Heritage Protection
Reception
Level 3, 400 George Street
BRISBANE QLD 4000
Business hours: 8:30am–4:30pm business days
Enquiries:
Permit and Licence Management
Phone: 1300 130 372 (option 4)
Fax: (07) 3330 5875
Email:

ATTACHMENT 1—DETAILS OF JOINT VENTURE PARTNERS

If more space is required to list all the joint venture partners, print off a blank copy of this page and attach to the application.

JOINT APPLICANT’S NAME(PRINT FULL NAME)
RESPONSIBLE PERSON/APPOINTED SIGNATORY
ABN/ACN
FULL RESIDENTIAL ADDRESS OR REGISTERED BUSINESS ADDRESS (NOT A POST OFFICE BOX ADDRESS)
POSTAL ADDRESS (IF DIFFERENT FROM ABOVE)
CONTACT PERSON
PHONE / FACSIMILE
EMAIL
JOINT APPLICANT’S NAME (PRINT FULL NAME)
RESPONSIBLE PERSON/APPOINTED SIGNATORY
ABN/ACN
FULL RESIDENTIAL ADDRESS OR REGISTERED BUSINESS ADDRESS (NOT A POST OFFICE BOX ADDRESS)
POSTAL ADDRESS (IF DIFFERENT FROM ABOVE)
CONTACT PERSON
PHONE / FACSIMILE
EMAIL

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[1]Affected and interested person is defined within sections 38 and 39 of the EP Act.