ShelterFoster

Application for a Wildlife Shelter or Foster-carer Authorisation

Applicants must be at least 16 years of age.

Applicants under 18 years of age will require a supporting declaration by their parent or legal guardian.

Before an application is granted, you may be contacted to arrange a site-visit to verify suitability of the specified premises by Forest and Wildlife Officers.

Personal details

First name (required) *

Other given names

Family name (required) *

Date of birth (required) *

Tick this box if Applicant is 16 or 17 years of age

Parental permission

Name of parent or legal guardian (required) *

Daytime contact telephone no. (required) *Note: If named as parent or legal guardian, we may contact you to verify your details and to confirm your consent for the making of this application.

Residential address (required) *

Street address (required) *

City (required) *

State (required) *

Postcode (required) *

Municipality (required) *

Tick this box if postal address is same as residential address

Postal address (required) *

Street address (required) *

City (required) *

State (required) *

Postcode (required) *

Contact details

Phone - personal (required) *

Email addressProviding an email address will allow a copy of this application form to be sent automatically to you for your records

How do you prefer us to contact you about this application/authorisation?

ElectronicHardcopy

Consent to disclose

NO, do not disclose my contact detailsYES, please disclose my contact details

By ticking 'YES' you are consenting to your contact details including name and telephone number(s) being disclosed to members of the public seeking to contact you about wildlife-related services, should you receive an authorisation to provide them.

This application

I wish to apply for a (required) *

Foster-Carer AuthorisationShelter Authorisation

Foster-carer may only operate at your residential address

Is a wildlife licence also operating at this address?

NoYes

My nominating Wildlife Shelter is:

Nominating shelter authorisation number (required) *

Name of shelter operator (required) *

Email address

Contact phone (required) *

I wish to operate from my residential address

Operational address (required) *

Street address (required) *

City (required) *

State (required) *

Postcode (required) *

Organisation or business name

My position in this organisation or business

Is a wildlife licence also operating at this address?

NoYes

Details of the veterinarian or surgery that will be assisting you in caring for wildlife

Name (required) *

Contact Phone (required) *

Veterinarian address (required) *

Street address (required) *

City (required) *

State (required) *

Postcode (required) *

Experience caring for wildlife

Do you have experience caring for wildlife? (required) *

NoYes

Previous authorisation number (if known)

List details of wildlife you have previously cared for:

Select species (required) *

Quantity (required) *

Treatment (required) *

Prior convictions

Have you been convicted of any offence under the Wildlife Act 1975, Wildlife Regulations 2013, Catchment and Land Protection Act 1994, Prevention of Cruelty to Animals Act 1986 or the Wildlife (Regulation of Exports and Imports) Act 1982 or similar interstate or federal legislation during the last 10 years? *

NoYes

Offence (required) *

Year (required) *

State (required) *

Collection, use and disclosure of personal information

Privacy and Data Protection Act 2014

The Department of Energy, Environment and Climate Action (DEECA) is committed to protecting personal information provided by you in accordance with the principles of the Victorian privacy laws. The information you provide will be used to monitor compliance with licence conditions and to provide information about any changes to legislative requirements. Your contact details may also be used by DEECA or its contracted service providers under confidentiality agreements to survey you about your experience with DEECA, seek feedback related to the keeping of wildlife and/or to provide you with information from DEECA relevant to your wildlife rehabilitation activities. An authorisation may not be issued if the information required is not provided.

The information you provide will also be made available to any authorised law enforcement agency.

You may access the information you have provided to DEECA by contacting the Customer Service Centre on 136 186.

Declaration by applicant

By making this application, I understand that there are penalties for making a false declaration and that any authorisation issued as a result of a false declaration will be cancelled and may affect my eligibility to care for wildlife in the future and that all details provided by me on this form are true and correct. I also consent to the collection, use and disclosure of my personal information for the purposes described above.