Form Corporate Application for a pre-design/pre-lodgement meeting OFFICIAL USE ONLY Important information for applicants DATE RECEIVED FILE REF PROJECT REF COMPLETE FORM A pre-design/pre-lodgement meeting will help you identify relevant environmental issues and the principles of sustainable development early in the planning stage of your proposal and will help the Department of Environment and Heritage Protection understand the level of impact or significance of the project. (Commercial and confidential information must be marked clearly) Applicant details ENTERED BY [SIGNATURE] DATE 1 Name of applicant PRINT FULL NAME: GUIDE 1. 2. 3. 4. The ‘applicant’ is the persons, or registered legal entity (not a business trading name) intending to carry out the activity and in whose name the applicable permits or licences are to be issued. If the applicant is a registered entity, enter name and title of the principal contact person for the application (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. 2 Responsible person/appointed signatory PRINT FULL NAME/TITLE: 3 ABN/ACN ABN/ACN: 4 Address and contact details FULL POSTAL ADDRESS: PHONE: FAX: MOBILE: EMAIL: Page 1 of 3 • 130321 • EM1125 • Version 3 ABN 46 640 294 485 Form Application for a pre-design/pre-lodgement meeting Project details 5 Description Briefly describe the proposal including any options being considered. Please indicate where there is scope for project modification. Technical reports or other planning work may be helpful in resolving issues about feasibility. Briefly describe the processes of your project as they relate to energy and water use and waste outputs and any other environmental issues that may be affected by the project. Attach any relevant information. DESCRIPTION: 6 Proposed site location(s) Where several site options are being considered, list all the alternative sites. Give as much information as possible to accurately locate the site(s), for example maps with contextual or boundary lines on plan or GPS boundary co-ordinates. Include surrounding areas and attach any relevant information. DESCRIPTION: 7 Offset requirements Is an environmental offset required (e.g. vegetation offset, biodiversity offset, Koala offset)? Yes No Don’t know Page 2 of 3 • 130321 • EM1125 • Version 3 Department of Environment and Heritage Protection Form Application for a pre-design/pre-lodgement meeting 8 Applicant’s certification I understand that 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. PRINT NAME AND POSITION OF SIGNATORY (E.G. MANAGER, OWNER, PARTNER, CEO): APPLICANT’S SIGNATURE: DATE: Thank you for taking the time to complete this form. An officer will contact you to arrange a pre-design/prelodgement meeting. Please return your completed application form to: Permit and Licence Management Implementation and Support Unit Department of Environment and Heritage Protection GPO Box 2454 Brisbane Queensland 4001 Enquiries: 1300 130 372 (Option 4) Email: [email protected] Privacy statement The Department of Environment and Heritage Protection (EHP) is committed to protecting the privacy, accuracy and security of your personal information in accordance with the Information Privacy Act 2009. EHP is collecting your personal information in order to tailor the meeting to best facilitate 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: [email protected] or telephone: (07) 3330 5448. Page 3 of 3 • 130321 • EM1125 • Version 3 Department of Environment and Heritage Protection
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