Permits & Concessions Unit
GPO Box 1448
DARWIN NT 0801 / Telephone: (08) 8999 4486
Facsimile: (08) 8999 4524
Email:
WILDLIFE REPORT / APPLICATION FOR RELEASE FORM
Territory Parks and Wildlife Conservation Act, section 55
If you are submitting this form for the purpose of a Wildlife Report, please note the following:
  • The permit holder must keep and maintain information that relates to Protected Wildlife for the purpose of a Wildlife Report.
  • The information must be kept up to date and must include details of all acquisitions, disposals, movement of wildlife and treatment administered.
  • The permit holder shall produce all Wildlife Report Forms for inspection by a Conservation Officer upon request.
  • Any intentionally misleading or false statements made on this report/application may result in legal action.
/ If you are applying to release an animal, please note the following:
  • It is the responsibility of the person wishing to release protected wildlife to gain approval from the Parks, Wildlife and Heritage Division prior to the wildlife being released by submitting this form to the Concessions and Permits Office (contact details above).
  • Please complete all applicable sections of this application. Failure to do so may result in delay or refusal to grant approval for release.
  • Please allow a minimum of five (5) working days for processing of your Wildlife Report / Release Form.

  1. DETAILS OF RESCUE To be completed by rescuer

Animalrescued (please be as specific as possible): / Date animal was rescued: / /
Exact location the animal was found (i.e. street address, closest street name, suburb, landmark):
Name of rescuer: / Contact phone:
Circumstances in which the animal was found. Please select:
Hit by car / Found by road / Found with dead mother / Attacked by cat/dog/predator
Entangled (i.e. fence or net) / Found abandoned / in unusual place / Fell from nest
Flew into window / Burnt or Electrocuted
Other:
Have you done anything additional (i.e. provided water, food or medication):
I hereby deliver this animal for assessment and treatment to this veterinary clinic or wildlife carer.
I understand that the animal may be transferred to an authorised wildlife carer or specialised wildlife facility for ongoing care.
I understand that this animal may be humanely euthanized if authorised staff deem that it is unable to be rehabilitated.
I agree to my contact details being provided to the wildlife carer or wildlife facility that receives this animal.
Signature of Rescuer: / Date: / /
  1. VETERINARY CLINIC DETAILSTo be completed by veterinarians

Name of veterinary clinic:
Name of veterinarian:
Length of time in veterinary care:
Contact phone: / Email address:
  1. WILDLIFE CARER DETAILSTo be completed by wildlife carer

Name: / Permit Number:
Address where animal is held:
Contact phone: / Email address:
3A. WILDLIFE CARER DETAILS To be completed by wildlife carers if multiple transfers
Transfer 1. Name of carer transferred to: / Permit Number:
Reason for transfer: / Date of Transfer:
Transfer 2. Name of carer transferred to: / Permit Number:
Reason for transfer: / Date of Transfer:
Transfer 3. Name of carer transferred to: / Permit Number:
Reason for transfer: / Date of Transfer:
  1. ANIMAL DETAILS To be completed by veterinary staff or wildlife carer

Species (please be as specific as possible):
Sex: M / F / Unknown / Age: Young / Sub-adult / Adult / Initial weight:
Please outline problem/disease/injury of animal:
  1. DETAILS OF ANIMALS TREATMENT To be completed by veterinary staff or wildlife carer

  1. FATE OF ANIMAL IF NOT RELEASED To be completed by veterinary staff or wildlife carer

Please select:
Dead on arrival / Died within 24 hours / Died after 24 hours / Euthanized
Escaped from care / Passed back to vet / Permanent care(Permit req.)
Other:
  1. IF THE ANIMAL IS READY FOR RELEASE PLEASE FILL OUT THE SECTION BELOW AND FORWARD TO THE CONCESSIONS AND PERMITS OFFICE FOR APPROVAL To be completed by veterinary staff or wildlife carer

Proposed release date: / / / Release location:
Release method (i.e. hard / soft / other):
  1. DECLARATION BY APPLICANT To be completed by veterinary staff or wildlife carer

  • I hereby declare that all details provided on this form are true and correct. I further declare that I am seeking approval to release the animal listed above and that the animal is suitably rehabilitated and can fend for itself.
  • Section 114 of the Territory Parks and Wildlife Conservation Act provides for a penalty of up to two (2) years imprisonment for a person, or up to 500 penalty units for a body corporate, for making a false or misleading statement in connection with a matter under this Act.

Applicants Name:
Applicants Signature: / Date: / /
  1. AUTHORISING OFFICER FOR RELEASE To be completed by wildlife ranger

APPROVED: Yes / No / Forwarded to Permits: Yes / No
Officers Name: / Position:
Signature: / Date: / /
Comments:
The Parks, Wildlife and Heritage Division adheres to the Northern Territory Government Privacy Statement, which can be found at:

Wildlife Report / Application for Release Form Page 1 of 3