Guide to completing this application
1.	This application form is to be used by landholders to apply for an approval to buy, possess, apply and dispose restricted S7 (RS7) poisons under the Medicines and Poisons Act 2019 (MPA) and the Medicines and Poisons (Poisons and Prohibited Substances) Regulation 2021 (Poisons Regulation). Information for rural landholders seeking to control invasive animals using RS7 poison is available at the Department of Health’s website.
2.	Please print clearly and answer all questions in full. You will be contacted if information is incomplete or additional information is required. This may delay the application process. 
3.	This application does not need to be completed by landholders:
•	participating in a local government coordinated 1080 baiting program or seeking to obtain Low-risk fluoroacetic acid baits (LRFAB) containing 0.5 g/Kg or less fluoroacetic acid from an authorised officer under the Biosecurity Act 2014 or the Nature Conservation Act 1992
•	wanting to buy manufactured (shelf-stable) LRFABs and who are the holders of a current General approval – Manufactured low-risk fluoroacetic acid baits
4.	Note: Fluoroacetic acid (1080) concentrate will only be authorised in the following exceptional circumstances:
•	In remote regional areas where the supply of baiting products by Councils is not available. Written confirmation from the relevant Council must be provided confirming that baiting services are not available; and
•	The applicant must provide written reasons why other baiting products, e.g. para-aminopropiophenone (PAPP) or 1080 pest ejector devices, manufactured baits or PAPPutty) is not used instead of 1080 concentrate; and
•	Possession of the prescribed competencies (see section 7 of the application form)
5.	Note: With the expiry of APVMA Permit (PER14004), Strychnine will no longer be available for invasive animal control after the 30 June 2024. For this reason, QLD Health will no longer grant approvals for strychnine.
6.	The documents listed below are required to be submitted with this application form. To avoid unnecessary delays, ensure you provide all the required documents together:
•	For individuals/partnership, a verified copy of proof of identification for each individual e.g. driver’s licence, birth certificate, passport;
•	For a company, a verified copy of a current company extract from the Australian Securities & Investments Commission (ASIC);
•	Verified copy of a recent local government rates notice or lease notice that identifies the property description (lot/plan number) of all land parcels to be baited, as proof of ownership/occupancy;
•	If you are not the property owner, you will need a consent letter from the owner stating that they give permission for you to lay poison baits on their property;
•	Verified copies of certificates of attainment for competencies specified in Section 7;
•	A scaled map showing details and features related to your intended baiting activities, see Section 9.
7.	Photocopied documents including evidence of identity must bear the signature, name and occupation of an authorised identifier (verified copy) i.e. signed by health or legal professionals, Public Health Unit officers, government representatives, public servants, bank officers.
8.	The person signing on behalf of an entity must be an Executive Officer or a person authorised to sign on behalf of the entity.
9.	Applications and attachments will be provided to the Department of Agriculture and Fisheries and the local government your properties are in, for advice and comments on your application.
10.	If the space provided in any section is insufficient, please attach additional documents with the required information, indicating clearly which section of the form it applies to. 
11.	Timeframes for processing of applications may take up to 90 days.
How to submit this application 
This application may be submitted by either email or post, if you require assistance in relation to completing your application form, contact the Public Health Regulation and Licensing Unit on (07) 3328 9310. 
To submit your application, send the attached application form, accompanied by all supporting documents (verified where required) to:
The Chief Executive
Queensland Health
Public Health Regulation and Licensing Unit
PO Box 2368
FORTITUDE VALLEY   QLD   4006
Electronic applications can be sent to: Licensing@health.qld.gov.au 	

	
Privacy statement – please read carefully
The personal information and documents collected for the purpose of this application will be securely stored, and only accessible and used by authorised persons for purposes in accordance with the Medicines and Poisons Act 2019 and Medicines and Poisons (Poisons and Prohibited Substances) Regulation 2021. Queensland Health may be required to make enquiries of, and exchange personal information with, other State, Territory or Commonwealth entities regarding any matters relevant to this application. The department will not disclose any personal information provided with this application and supporting documents to any other third parties without your consent unless required or authorised by law. The Information Privacy Act 2009 (Qld) sets out the obligations for the collection and handling of personal information by Queensland Health. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au.

SECTION 1 – Type of application	
	New general approval (section 75 of the MPA)
(if your approval has expired, you need to apply for a new approval)	
	Amendment to an existing general approval – Approval Number:       (section 78 of the MPA)
	Complete sections 2, 12 and all sections that require amending	
	Replacement of lost/destroyed general approval – Approval Number:       (section 83 of the Poisons Regulation)
Complete section 2 and sections 10 – 12	
SECTION 2 – Applicant details	
Provide details of the individual/entity seeking the approval (i.e. the legal entity)	
 Individual	 Partnership	 Company	 Other      	
*If you are not the property owner, you will need to provide a consent letter from the owner giving permission for you to lay baits on their property.	
Full name of applicant:      	
Trading name:      	ABN/ACN (if applicable):      	
Phone:      	Email:      	
Postal address:      	Town/Suburb:      	P/C:      	
For individuals, provide your personal details; for other entities, provide the personal details of directors/chairpersons or partners. Attach further information if required using the ‘Additional Directors/Chairpersons/Partners attachment’.	
Executive Officer or other person authorised to sign on behalf of the entity Director/Chairperson/Partner 1	
Title:      	Surname:      	Given name/s:      	
Position:       	
Phone:      	Email:      	
Executive Officer or other person authorised to sign on behalf of the entity Director/Chairperson/Partner 2	
Title:      	Surname:      	Given name/s:      	
Position:       	
Phone:      	Email:      	

SECTION 3 – RS7 poisons being applied for  	
 1080 Concentrate – Quantity of concentrate requested:       ml	*1080 concentrate will only be authorised in exceptional circumstances see Point 4 of the guideline to completing this application	
 PAPP manufactured shelf-stable baits 	* There is no restriction on the quantity of LRFABs or manufactured PAPP baits purchased under this general approval	
 Low-risk fluoroacetic acid baits (LRFAB)  		
 Fluoroacetic acid (1080) capsules for ejector devices – Number of capsules requested:         	
 PAPP capsules for ejector devices – Number of capsules requested:       	
 PAPP lethal paste – Number of tubes requested:        	
 Other – provide details and quantity requested:        	
SECTION 4 – Duration of Approval	
Term of Approval sought:	  1 year 	  2 years	  3 years	
SECTION 5 – Previous approvals	
Do you currently have any 1080, strychnine,  PAPP capsules or PAPP paste in your possession obtained under a previous approval or permit?	1080 concentrate 	 No   Yes	Qty:        ml	
	1080 capsules	 No   Yes	Qty:        capsules	
	Strychnine  	 No   Yes	Qty:        grams	
	PAPP capsules	 No   Yes	Qty:        capsules	
	PAPP paste tubes	 No   Yes	Qty:        tubes	
SECTION 6 – Storage 	
Storage address:  same as postal address (section 2) or provide storage address:      	
Describe where/how the poison will be stored securely e.g. locked in safe or secure cabinet:       	
SECTION 7 – Competency requirements for control of invasive animals (refer to Departmental Standard – ‘Competency requirements for authority holders dealing with poisons’.	
PAPP capsules, 1080 capsules, PAPP paste		AHCCHM304 – Transport and store chemicals (equivalent competency – AHCCHM304A) 	
		AHCCHM307 – Prepare and apply chemicals to control pest, weeds and diseases (equivalent competencies – AHCCHM303 and AHCCHM303A)	
		Other (please indicate)      	
	If you are seeking to obtain fluoroacetic acid concentrate you will also require the competency detailed below in addition to these competencies.	
1080 concentrate 		AHCPMG312 – Apply poison baits for vertebrate pest control in rural and environmental landscapes	
		Other (please indicate)      	

SECTION 8 – Details of baiting sites	
Provide details about the properties where baits will be applied. List the property descriptions (lot and plan numbers) for all land parcels you intend to bait. Ensure your local government rates notice lists all land parcels to be baited, if a parcel of land is not listed on the rates notice you will be required to provide evidence of ownership.
Please use the form at the end of the application if you need to add additional properties	
1.
Property description (lot/plan):      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
•	Neighbouring dwelling:       metres/km	2.
Property description (lot/plan):      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
•	Neighbouring dwelling:       metres/km	
3.
Property description (lot/plan):      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
•	Neighbouring dwelling:       metres/km	4.
Property description (lot/plan):      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
•	Neighbouring dwelling:       metres/km	
Section 9 – Map requirements	
Your application must include a map that provides accurate information about the properties to be baited including:	
•	Property boundaries
•	Locations or areas where baits will be laid
•	Property access points (entrances/exits)
•	Stock routes	•	Warning sign locations
•	Roads
•	Water courses
•	Townships and neighbouring dwellings	
The map must be to an appropriate scale to enable the distance between bait locations and other features to be determined. A minimum distance of 2 kilometres outside the property boundaries is required to be shown to identify sensitive features including neighbours’ dwellings and townships. Please note that you may be asked to resubmit maps that are not clear or are not to an appropriate scale, which may delay the application process.
Map legend
Your map must include a legend that details the location of important features as indicated below:
Example legend symbols:   ⧖ - entrances/exits;   █ - dwellings;   ▨ - proposed baiting locations/areas.
 ~~ - water courses (blue);   ‖ - roads (red);   ◊ - locations of poison warning signs;            - stock routes
Alternative symbols may be used providing they are clear and can be understood by the person assessing your application. If different symbols are used, ensure their meaning is clearly explained in your map’s legend.	
SECTION 10 – Requesting a replacement general approval	
My general approval was: 	 Lost      	 Stolen      	 Damaged	

SECTION 11 – Disclosure (relates to individual applicants or where this disclosure is relevant to the named entity itself – not the Executive Officer or other person authorised to sign on behalf of the entity)	
Have you, the applicant:	
a)	Been convicted of an indictable offence (drink driving and minor traffic offences are not indictable offences)?	 Yes    No	
b)	Been convicted of an offence against the Medicines and Poisons Act 2019, Health Act 1937 (including the Health (Drugs and Poisons) Regulation 1996) (repealed) or equivalent legislation in another Australian jurisdiction?	 Yes    No	
c)	Held a licence, approval and/or an endorsement under the Medicines and Poisons Act 2019, Health Act 1937 (including the Health (Drugs and Poisons) Regulation 1996) (repealed) or equivalent legislation in another Australian jurisdiction, that was suspended or cancelled?	 Yes    No	
d)	Been refused a licence, approval and/or an endorsement under the Medicines and Poisons Act 2019, Health Act 1937 (including the Health (Drugs and Poisons) Regulation 1996) (repealed) or equivalent legislation in another Australian jurisdiction?	 Yes    No	
Provide further details to questions answered 'yes' as an attachment to your application	
SECTION 12 – Consent and declaration	
	I consent to the chief executive, Queensland Health (or delegate) making enquiries of, and exchanging information with other Queensland authorities, any Australian state or territory, or of the Commonwealth, regarding any matters relevant to this application. If relevant information cannot be obtained from other entities, the chief executive (or delegate) will determine the application on the information available.	
	I declare that, to the best of my knowledge, all information provided in this application form, or in an attachment provided, is true and correct.	
	I understand that if anything has been stated in this application form, or in an attachment provided, that is false or misleading, any substance authority granted may be suspended or cancelled.

Signature (sign or insert an image of your signature):

Please complete the below details

Full name of applicant or authorised representative:

Position:

Date signed:

Additional baiting sites

Details of baiting sites	
Provide details about the properties where baits/traps will be applied. List the property descriptions (lot and plan numbers) for all land parcels you intend to bait. Ensure your local government rates notice lists all land parcels to be baited, if a parcel of land is not listed on the rates notice you will be required to provide evidence of ownership.	
5.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km	6.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km	
7.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km	8.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km	
9.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km	10.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km	
11.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km	12.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km	
13.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km	14.
Property description:      
Property name:      
Property address:      
Property size:      
Distance from baiting area to:
•	Nearest township/settlement:       metres/km
Neighbouring dwelling:       metres/km