Form

Applicant suitability questionnaire

Environmental Protection Act 1994

Applicant suitability questionnaire

Important information for applicants

The Department of Environment and Science administers several pieces of legislation, many of which require individuals applying for a permit or licence to pass an ‘applicant suitability test’ before an approval to carry out certain types of activities can be granted. Where the applicant is a corporation, this questionnaire applies to all executive officers of the corporation.

This questionnaire is a statutory declaration and the applicant must be aware that there are serious consequences for failing to answer the questions truthfully. This may include cancellation of a licence or permit, or initiation of court proceedings. Only complete those questions about legislation relevant to your application.

Questions -Environmental Protection Act 1994 / Details
Have you been convicted of an offence under this legislation? If yes, provide details. / YES NO
Have you been issued with one or more penalty infringement notices under this legislation? / YES NO
Have you ever had an environmental authority or an equivalent authority from another state or country that was cancelled or suspended? If yes, provide details about the authority, when it was cancelled or suspended and the reason’s why. / YES NO
Have you ever breached any condition of an environmental authority under this legislation? / YES NO
Have you ever been issued with an environmental protection order under this legislation? Provide details. / YES NO
Have you been convicted of any offence under environmental legislation in another state or country? / YES NO
Do you have any formal qualifications that may be relevant to complying with conditions of an environmental authority? Provide details. / YES NO
Have you owned or operated a business with activities similar to that for which you are making this application? If yes, include details about size, location and nature of the operation. / YES NO
Do you have any knowledge of environmental protection legislation or any particular knowledge of environmental issues and the local areas that may be relevant to the activities to be conducted under the permit? / YES NO
Do any of your previous roles and responsibilities provide you with knowledge that may be relevant to your application? If yes, provide details. / YES NO
Questions - Nature Conservation Act 1992 / Details
During the past 10 years, have you ever (in Queensland or elsewhere) been found guilty of any criminal offence? (Note: Does not include simple traffic offences such as parking, speeding.) / YES NO
Have you ever been convicted of an offence under this or similar legislation (in Queensland or elsewhere)? If yes, provide details of demerit points incurred. / YES NO
Have you ever had an equivalent permit from another State or country that was suspended and/or cancelled? If yes, provide details about the permit and when it was suspended and/or cancelled. / YES NO
Have you been convicted of an offence relating to cruelty to an animal, wildlife or a protected area? If yes, when were you convicted? / YES NO
Have you owned or operated a business or conducted recreational activities similar to that for which you are making this application? If yes, include details about the size, location and nature of the operation. / YES NO
Do you have any knowledge of protected areas legislation that may be relevant to the activities to be conducted under the permit? If yes, provide details. / YES NO
Do you have any particular knowledge of nature conservation principles, cultural values and the local area? If yes, provide details. (Note: This question does not relate to activities outside of protected areas. Mark “N/A” if this is the case.) / YES NO
Do any of your previous roles and responsibilities provide you with knowledge that may be relevant to your application? If yes, provide details. / YES NO
Questions -Cultural Record (Landscapes Queensland and Queensland Estate) Act 1987 / Details
Do you have any formal qualification that gives evidence of your ability to undertake the activity provided for in the licence? If yes, provide details. / YES NO
Do you have any other knowledge such as a traditional owner’s cultural knowledge that demonstrates your ability to undertake the activity provided for in the licence? If yes, provide details. / YES NO
Do you have any type of work experience that may be relevant to your ability to undertake the activity provided for in the licence? If yes, provide details. / YES NO
Do you have sufficient financial resources to undertake the activity provided for in the licence? / YES NO
Do any of your previous roles and responsibilities provide you with knowledge that may be relevant to your application? If yes, provide details. / YES NO
Questions - Recreation Areas Management Act 1988 / Details
Have you ever been convicted of an offence under this legislation or similar legislation in another state or country? If yes, provide details including number of demerit points incurred. / YES NO
Have you ever had an equivalent permit from another State or country that was suspended and/or cancelled? If yes, provide details including when it was cancelled. / YES NO
Have you been convicted of an offence relating to cruelty to an animal, wildlife or a protected area? If yes, provide details including when you were convicted. / YES NO
Have you owned or operated a business or conducted recreational activities similar to that for which you are making this application? If yes, provide details about the size, location and nature of the operation. / YES NO
Do you have any knowledge of recreation areas legislation that may be relevant to the activities to be conducted under the permit? If yes, provide details. / YES NO
Do you have any particular knowledge of nature conservation principles, cultural values and the local area? If yes, provide details. (Note: This question does not relate to activities outside of protected areas. Mark “N/A” if this is the case.) / YES NO
Do any of your previous roles and responsibilities provide you with knowledge that may be relevant to your application? If yes, provide details. / YES NO

Is there any other information that may be relevant to your suitability to hold a licence, permit, approval or other type of authority? If yes, provide details. YES NO

Details:

Applicant’s certification

Note: If you have not told the truth in this application, you may be liable for prosecution under the relevant Acts or Regulations.

  • I do solemnly and sincerely declare that the information provided is true and correct to the best of my knowledge.
  • I understand that information supplied on or with this application form may be disclosed publicly in accordance with the Freedom of Information Act 1992 and the Evidence Act 1977.

Applicant Name:
Signatureof Applicant: / Date:
Witness Name:
Signatureof Witness: / Date:

Privacy Statement

The Department of Environment and Scienceis 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 the Environmental Protection Act 1994in order to assess your application under that Act. The information will only be accessed by authorised employees within the department. Some of this information may be shared with Department of Natural Resources and Mines. 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 telephone13 74 68.

Page 1 of 5 • ESR/2015/1850 • Version 2.02 • Effective: 3 APR 2015Department of Environment and Science