Guide to completing this application
1.	This application is to be used by landholders to apply for an approval to buy, possess, apply or dispose of manufactured (shelf-stable) low-risk fluoroacetic acid baits (LRFABs) 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. See in particular Guidelines for storage of poisons and prohibited substances and Regulated poisons disposal requirements for storage and disposal information.
2.	NOTE that the label provided with the RS7 poisons outlines other requirements that you need to comply with.
3.	Successful applicants can present their approval to a licenced RS7 retailer (e.g. stock and station agent) to buy the manufactured LRFABs. Licenced retailers can only sell to the person whose name is on the approval or an employee/agent authorised by the approval holder to buy the LRFABs.
4.	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.
5.	This application does not need to be completed by landholders: 
a.	participating in a local government coordinated 1080 baiting program, or seeking to obtain low-risk fluoroacetic acid baits (containing 0.5 g/Kg or less fluoroacetic acid) from an authorised officer under the Biosecurity Act 2014 or the Nature Conservation Act 1992
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:
a.	For individuals, a verified copy of proof of identification for each individual e.g. drivers’ licence (both sides), birth certificate, passport.
b.	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.
c.	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. This includes where a company or other organisation is listed as the owner.
7.	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.
8.	The Department may carry out inquiries, including seeking advice from other state and local government entities, in relation to your application as considered necessary.
How to submit this application
This application must be submitted by email, applications should be sent to: LRFAB@health.qld.gov.au
If you cannot submit your application by email or require assistance in relation to completing your application form, contact the Environmental Hazards Unit on (07) 3328 9310 or email environmentalhazards@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 – Applicant details	
*Provide details of the individual seeking the approval	
Full name of applicant:      	
Phone:      	Email:      	
		
Address (not a PO Box):      	Town/Suburb:      	P/C:      	
Postal address:    as per above, or        	
*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.	
SECTION 2 – 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 page at the end of the application if you need to add additional properties	
1.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	2.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	
3.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	4.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	
SECTION 3 – Storage 	
Storage address:  same as physical 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 4 – Rates notices and proof of identity	
Rates notice/s identifying baiting sites listed in section 2 has been attached                                    Yes     
Proof of identity has been attached                                                                                                    Yes     	
SECTION 5 – Disclosure	
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 6 – Consent and declaration	
	I consent to the Chief Executive 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 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 with this application, that is false or misleading, any substance authority granted may be suspended or cancelled.	
Full name of applicant:
     

By submitting this form by email, your name above and email address will be evidence of you signing this form.	Position of applicant:
     	Date (DD/MM/YYYY):
     	

Additional baiting sites

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.	
5.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	6.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	
7.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	8.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	
9.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	10.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	
11.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	12.
Property description (lot and plan):      
Property name:      
Property address:      
Property size:      	
13.
Property description:      
Property name:      
Property address:      
Property size:      	14.
Property description:      
Property name:      
Property address:      
Property size: