1.	Type of Application
•	Request for Scoping Document OR	•	Application for Environmental Significance Opinion 
 Section 138AA Planning and Development Act 2007 OR	
•	 Request for Exemption to Provide Environmental Impact Statement Section 211 Planning and Development Act 2007 OR	•	Additional Information as requested by the planning and land authority for any application for Scoping, EIS, or ESO	

If you attended a pre-application meeting or written pre-application advice in relation to the proposal that is the subject of this application please provide proposal number                           Proposal Number 20_______________

Project Name	

Project Description	

	

2.	Lease/Site Details Please Print

Provide the following details for each lease/site:

Site 1
Block:	
	Section:		Suburb:		
		
Street Address (if applicable)	

Land Use Zone/s applicable to this site	

Site 2
Block:	
	Section:		Suburb:		
		
Street Address (if applicable)	

Land Use Zone/s applicable to this site	

Site 3
Block:	
	Section:		Suburb:		
		
Street Address (if applicable)	

Land Use Zone/s applicable to this site	

If more than three sites please provide details on separate page
3.	Applicant Details Please Print

Surname	
		First Name		
		
Name of Company/Department/ Government Agency 	

Position held in Company/Department/Government Agency		
		
Australian Company/Business Number (ACN/ABN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

4.	Lessee (Property Owners) or Government Land Custodian Details Please Print

SITE 1

1st Lessee or Land Custodian Details
	               2nd Lessee or Land Custodian Details	
Full Name:
		Full Name:		
				
Company Name:
		Company Name:		
				
Position Held in Company:		Position Held In Company:		
				
ACN Number:
		ACN Number:		
				
Postal Address:

	Postal Address:		
				
Telephone BH:		Telephone BH:		
				
Mobile:
		Mobile:		
				
Email Address:
		Email Address:		

SITE 2

1st Lessee or Land Custodian Details
	               2nd Lessee or Land Custodian Details	
Full Name:
		Full Name:		
				
Company Name:
		Company Name:		
				
Position Held in Company:		Position Held In Company:		
				
ACN Number:
		ACN Number:		
				
Postal Address:

	Postal Address:		
				
Telephone BH:		Telephone BH:		
				
Mobile:
		Mobile:		
				
Email Address:
		Email Address:		

SITE 3

1st Lessee or Land Custodian Details
	               2nd Lessee or Land Custodian Details	
Full Name:
		Full Name:		
				
Company Name:
		Company Name:		
				
Position Held in Company:		Position Held In Company:		
				
ACN Number:
		ACN Number:		
				
Postal Address:

	Postal Address:		
				
Telephone BH:		Telephone BH:		
				
Mobile:
		Mobile:		
				
Email Address:
		Email Address:		

All lessees must sign authorising the lodgement of this application. In doing so the lessee gives authority to the applicant to negotiate any dealings in relation to the application through to its determination.  If there are more than two lessees please ensure that the details and authorisation are attached to the application.

If a lessee signature can not be obtained and either a land acquisition or lease withdrawal is underway to facilitate the project to which the EIS Scope relates then the applicant must submit documentary evidence that such land acquisition or lease withdrawal is occurring and that the lessee is aware of the project to which the EIS Scope relates.

5.	EIS Requirements – complete this part for Application for Scoping Document ONLY

Please identify why your proposal requires an Environmental Impact Statement and include applicable references to the Planning and Development Act 2007 (P&D Act).

•	The proposal is a type listed under schedule 4 of the P&D Act.  Please list item numbers: ______   ______   ______   ______   ______

•	The proposal is not an EXEMPT, CODE, or MERIT track development where the development is allowed under an existing lease

•	The proposal is permissible under the National Capital Plan but listed as prohibited in the relevant development table

•	The proposal has been declared under section 124 and section 125 of the P&D Act 
•	
•	The proposal is not listed anywhere in the relevant development table (in-nominate use)	
6.	Complete this part for Application for Environmental Significance Opinion ONLY
S138AA Planning and Development Act 2007

Are you seeking an Environmental Significance Opinion?	
•	YES	
•	NO	

IF YES - identify the item(s) for opinion under Schedule 4 of the Planning and Development Act 2007

•	Section 4.2 Item 3 (c)	
•	Section 4.2 Item 3 (d)	
•	Section 4.3 Item 1	

•	Section 4.3 Item 2 (a)	
•	Section 4.3 Item 2 (b)	
•	Section 4.3 Item 3	

•	Section 4.3 Item 6	

	

Note: Applications for Environmental Significance Opinion from the ACT Heritage Council must be accompanied by a Statement of Heritage Effects prepared by a suitably qualified heritage professional regarding the potential impacts of the proposal.

7.	Complete this part for Request for Exemption to Provide Environmental Impact Statement ONLY
S.211 Planning & Development Act 2007

The Minister may exempt a development proposal from a requirement to include an EIS if satisfied that the expected environmental impact of the development proposal has already been sufficiently addressed by another study, whether or not the study relates to the particular development proposal.

If the proposal is a type listed under Schedule 4 of the P&D Act, please list the item numbers: _____    _____   _____   _______

Please supply supporting documentation to justify s211 consideration and a statement as to how the supporting documentation satisfies the requirement of s.211 and s50A of the P&D Regulation.
	
•	Documentation Attached
	
8.	Environment Protection and Biodiversity Conservation Act 1999

Does the Commonwealth Environment Protection and 
Biodiversity Conservation Act 1999 (EPBC) affect your proposal?	
•	NO
	
•	YES

If YES - attach copies of the Commonwealth Department of the Environment "Notification of Referral Decision" and "Decision on Assessment Approach" 

NOTE: Copies of these documents must be attached to this application form before it can be accepted for processing by the planning and land authority.

IF NO - Have you had meetings/discussions with the Department of the Environment?

If YES - Please provide the contact details of the Department of the Environment officer
	
•	NO
	
•	YES

Name: ________________________________________	
Contact No. ________________________________________________

	

9.	Your Proposal  – Required for ALL application types

Please attach to this application form a document that provides sufficient detail to enable prescribed entities to obtain an understanding of the full extent of your proposal and any associated works, including: 

1.	a statement outlining the objectives of the project and why it is needed;

2.	a description of the nature/type of project proposed by providing location map(s) of the project site(s), preliminary design drawings and satellite/aerial photographs;

3.	a preliminary risk assessment (PRA) based on the guidance document attached to this form (not required for an ESO application);

4.	a description of the natural conservation values of the site based on the considerations listed in the “Preparation of an application for scoping and preparation of an ESO" guideline available from the EPD website;

5.	a description of measures within the proposal that seek to avoid and minimise (and as a last resort offset) impact on identified conservation values (for ESO and Section 211 applications only);

6.	any decision made under the EPBC Act in relation to this proposal.

7.	For s211 applications only, the following additional information is required:

•	details of qualifications, expertise and experience of the person(s) who conducted previous studies supporting the application;
•	details of public consultation undertaken, as part of statutory requirement, for projects or previous studies included as supporting documentation undertaken. Details of public consultation not required for a statutory process should also be included;
•	verification from a qualified person that the information in the previous studies supporting the application is still current. 

10.	Prescribed Entities

Have you had any meetings/discussions with relevant prescribed entities?	
•	  NO
•	YES	

IF YOU ANSWERED YES TO THE QUESTION – please complete the following table and provide meeting minutes:

ENTITY (please tick)	DATE/s OF MEETING/s	ENTITY CONTACT 	
•	ACTEW Corporation Ltd	
		
•	ACTEWAGL Distribution	
		
•	Conservator Flora & Fauna	
		
•	Emergency Services	
		
•	Environment Protection	
		
•	Heritage Council	
		
•	Health Policy	
		
•	Territories & Municipal Services	
		
•	Custodian of the Land	
		
•	Other: _________________________
                       Please specify 			

11.	Conflict of Interest Declaration

Does the applicant or lessee have any association with EPD staff?	•	NO
•	YES	
If YES please provide details:	

NOTE: There are penalties for deliberately giving false and misleading information. The planning and land authority or Minister may revoke an approval if satisfied that the approval was obtained by fraud or misrepresentation.

12.	Other Application Requirements

DOCUMENTATION AND PLANS

All required documentation must be provided in an electronic format on compact disc/DVD or via email and meet the following requirements (Form can be submitted in hardcopy if lodged over the counter)

•	Each document must be saved as a PDF and named in accordance with the naming convention as detailed on the EPD website. 
•	All plans must be to scale.
•	All plans must be rotated to the correct orientation i.e. they are the right way up when opened
•	All plans are to be clear and concise and generally consistent with Australian Standard 1100.301 - 1985 and Australian Standard 1100.301 supplementary - as updated from time to time.
•	The documentation provided on CD/DVD either over the counter or via an electronic lodgment process (email or internet) will be considered to be the relevant documentation associated with this application.

HARDCOPY DOCUMENTATION REQUIREMENTS FOR ALL APPLCATION TYPES

In addition to the documentation being provided on CD/DVD one bound and one unbound hard copy must also be provided. 

13.	 Applicant and Lessee Declaration

I/we the undersigned, declare that this application is accompanied by all of the required information and or documents and understand that the documentation provided on CD/DVD or via electronic lodgement process (email or internet) will be considered to be the relevant documentation associated with this application; and understand that the information submitted with this application form will undergo a documentation check.  I/we understand that this application will be considered lodged once the relevant application fees have been paid;

I/we hereby authorise ACT Government officers to access the subject property(s) for the purpose of evaluating the proposal;

I/we the undersigned (lessee) appoint the applicant whose name and signature appear below to act on my/our behalf in relation to this application.  This authorises the applicant to pay for all application fees, bonds, and securities, liaise with the planning and land authority when required, alter amend or provide further information as necessary and receive any communications relating to this application;

I/we declare that all the information given on this form and its attachments is true and complete;

If signing on behalf of a company, organisation or Government agency: -
I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company, organisation or Government agency.

Applicant Signature (s)	
	Date		
SITE 1				
1st Lessee Signature	
	Date		
				
2nd Lessee Signature	
	Date		
				
Govt Land Custodian Signature 
(unleased land only)	
	Date		
				
Delegate of the planning and land authority 
(unleased land only)	
	Date		

SITE 2				
1st Lessee Signature	
	Date		
				
2nd Lessee Signature	
	Date		
				
Govt Land Custodian Signature 
(unleased land only)	
	Date		
				
Delegate of the planning and land authority 
(unleased land only)	

	Date		
SITE 3				
1st Lessee Signature	

	Date		
				
2nd Lessee Signature	

	Date		
				
Govt Land Custodian Signature 
(unleased land only)	

	Date		
				
Delegate of the planning and land authority 
(unleased land only)	

	Date		

Privacy Notice
The personal information on this form is provided to the Environment and Planning Directorate (EPD) to enable the processing of your application. The collection of personal information is authorised by the Planning and Development Act 2007.  If all or some of the personal information is not collected EPD cannot process your application. The Planning and Development Act 2007 requires the details of applications, decisions and orders to be kept on a register and made available for public inspection. Information and documentation relevant to a development application may be made available via the Internet. The personal information you provide may be disclosed to Australian Bureau of Statistics, ACT Revenue Office, the Registrar General’s Office, ACTEW Corporation, ActewAGL, Territory and Municipal Services Directorate and other Government agencies with a direct interest in the development assessment process.  The information may also be disclosed where authorised by law or court order, or where the Directorate reasonably believes that the use or disclosure of the information is reasonably necessary for enforcement-related activities conducted by, or on behalf of, an enforcement body. EPD’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by EPD, and how you may complain about an alleged breach of the Territory Privacy Principles. The EPD Information Privacy Policy can be found at www.environment@act.gov.au 

Does the Commonwealth Environment Protection and Biodiversity Conservation Act 1999 (EPBC) affect your proposal?
The EPBC came into operation on 16 July 2000. It establishes an environmental assessment and approval system that is separate and distinct from the ACT system. It does not affect the validity of ACT development assessment and approval processes, but may affect the assessment track. The ACT cannot provide preliminary advice on whether a proposal falls within the definition of a controlled action, or requires referral to the Commonwealth. You should consult with the Commonwealth to determine if your proposal is a controlled action before seeking any approvals under the Planning and Development Act 2007. For information about the EPBC, including the referral process and when a referral should be made, contact the Commonwealth Department of the Environment www.environment.gov.au 

Contact Details:
Environment and Planning Directorate
Customer Service Centres
GPO Box 158, Canberra City 2601
8 Darling Street Mitchell, ACT 2911
16 Challis Street Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Phone: (02) 6207 1923	TTY: (02) 6207 2622
Email: epdcustomerservices@act.gov.au	Website: www.environment@act.gov.au