PA Action St ERA ESR-2015-1791 Completed 02-2023

Application form

Development application Form 1 - Application details—attachment for an
application for an environmental authority

Attachment 1

Joint applicants and appointment of principal applicant

We are joint applicants for this environmental authority application and hereby appoint as the

principal applicant to receive statutory documents relating to this application.

 

Name - individual or contact person if applicant is an organisation”

Suitable Operator Reference Number*

 

Organisation name, including trading name (“if an organisation)

ABN/ACN (“if an organisation)

 

Residential or registered business address (not a post office box)*

Phone*

 

Postal address (if same as above, state “AS ABOVE”) *

Facsimile

 

Email*

 siIndicate if you want to receive
correspondence via email

 

Signature*

Date*

 

 

Name - individual or contact person if applicant is an organisation*

Suitable Operator Reference Number*

 

Organisation name including trading name (“if an organisation)

ABN/ACN (“if an organisation)

 

Residential or registered business address (not a post office box)*

Phone*

 

Postal address (if same as above, state “AS ABOVE”)*

Facsimile

 

Email*

1 Indicate if you want to receive
correspondence via email

 

Signature*

Date*

 

 

Name - individual or contact person if applicant is an organisation*

Suitable Operator Reference Number”

 

Business name including trading name (“if an organisation)

ABN/ACN (“if an organisation)

 

Residential or registered business address (not a post office box)*

|

Phone*

 

Postal address (if same as above, state “AS ABOVE”)*

Facsimile

 

Email*

C1 siIndicate if you want to receive
correspondence via email

 

Signature*

 

 

Date”

 

 

Page 11 of 12 * ESR/2015/1791 + Version 8.00 + Last reviewed: 12 AUG 2021

Department of Environment and Science