1 Application1.1 Proposed licence purpose

PO Box 153 Maffra Vic 3860 Email: srw@srw.com.au Phone: 1300 139 510 Fax: 03 5139 3150

Application for licence to take & use surface water and/or construct & operate a dam or pumpApplication for water corporation’s approval for a licence to take & use water and construct & operate works (under sections 51 & 67 of the Water Act 1989)

Privacy collection statement:The information from this form is collected under the Water Act 1989 in order to process this transaction. The information is used to maintain the State Water Register and to provide statistical water market information. Most of the information in the water register is available to the public.

Who this application form is for:• Any landowner or their authorised representative who plans to construct a new works (dams and/or pumps) that will be used to take and use

surface water. This application combines the requirements for:

• Take and Use Licence (licence to extract and use surface water – Section 51)

• Licence to Construct Works (Section 67)

• Licence to Operate Works (Section 67)

What to do:• readtheaccompanyingfactsheetandfeeschedulebeforeyoufillouttheform,plustheinformationnotesatthebackofthisform.

• complete the form

• Iftheproposedworksfitthecriteriaforbeingahazardousoron-streamdam,ensuresection5isalsocompleted.

• Thisapplicationmayrequiresections3,4&5tobecopiedandattachedtotheformifmultipleworksarerequired.

• checkyouhavefilledeverythingincorrectly.Missinginformationcandelayyourapplication.Incorrectinformationmay result in your application being refused. We will return illegible or incomplete applications.

• sendtheformtoSouthernRuralWater,POBox153,Maffra,VIC,3860withthefollowing:

• your payment (cheque or money order)

• copy of title

• photocopied map showing the location

If you have any questions or concerns about your application, please phone us on 1300 139 510.

Tick one or more: Officeuseonly:

New licence to construct works WLI

New licence to operate works WLI

Newlicencetotake&usewater BEI

Form 56

1.2 Applicant(s), signatures & declarationPlease print name(s) in full and in capital letters. All applicants must sign. Illegible applications will be returned. If there are additional applicants please ensure that Annexure 6 is also completed. All notices will be sent to the postal address of the first named party in the State Water Register.

I/we the undersigned certify that the information provided in this application is true and correct.

I/we understand that this information may be referred to other organisations and/or advertised as part of the application and assessment process or released if reasonably required by government business, requested by lawful orders, or in the public interest; particularly in regard to open disclosure of generally collected water entitlements.

Individual applicant(s):

Given name(s):

____________________________________________

Surname:

____________________________________________

Signature:

____________________________________________

Given name(s):

____________________________________________

Surname:

____________________________________________

Signature:

____________________________________________

Dated: _______ / _______/ ________If there are more than two individual applicants please complete Annexure 6. All applicants must sign the declaration.

If applicant is a company:

Name of company:_____________________________________________________________________________________ ABN:___________________________

Given name(s):

________________________________

Surname:

________________________________

Signature:

________________________________

Position:

________________________________

Given name(s):

________________________________

Surname:

________________________________

Signature:

________________________________

Position:

________________________________

Dated: _______ / _______/ ________ If there is more than one applicant company please complete Annexure 6. All applicants must sign the declaration.

Note that the person(s) who signs on behalf of a company must be authorised to do so, for example, a company secretary or director. Southern Rural Water will not accept liability if this form is signed by a person who is not authorised to do so.

1.3 Details of principal applicant (e.g. owner or lessee)Name:____________________________________________________________________________________________________________________________________

Property address:__________________________________________________________________________________________________________________________

Postal address (if different from property):_____________________________________________________________________________________________________

Town:________________________________________________________________________________________________ Postcode:_______________________

Telephone: ______________________ Mobile: _________________________ Email: ________________________ Fax: ____________________________

Form reference:Version 3

Valid at 17th September 2009

Time and Date Stamp

Please provide details of your proposed use for assessment purposes:

(i) Owner type (select one) Private (e.g. farmer)

Other: ________________________________

________________________________________

________________________________________

________________________________________

(ii) Method of taking (select one)

Direct extraction from waterway Extractionfromawaterwaytofillanoff-waterwaydam

Extractionfromanon-waterwaydam

Extraction with full return to waterway

Harvestingusinganoff-waterwaydam

In-stream(e.g.fishfarm)

(iii) Basin: ______________________________

_________________________________________

(iv) Waterway: __________________________

_________________________________________

1.4 Alternative contact details (e.g. farm manager or other contact person)Name:______________________________________________________________ Relationship to applicant:____________________________________________

Address:__________________________________________________________________________________________________________________________

Town:________________________________________________________________________________________________ Postcode:_______________________

Telephone: ______________________ Mobile: _________________________ Email: ________________________ Fax: ____________________________

1.5 Lodging party (if applicable)The lodging party may be a water broker or solicitor coordinating the application.

Name:______________________________________________________________ Surname / Company:____________________________________________

Address:___________________________________________________________ Party No. PTY

Town:________________________________________________________________________________________________ Postcode:_______________________

Telephone: ______________________ Mobile: _________________________ Email: ________________________ Fax: ____________________________

1.6 ReferralsTheEnvironmentProtection&BiodiversityConservation(EPBC)Actwasintroducedin1999.

TheEPBCActprovidesalegalframeworktoprotectandmanagenationallyandinternationallyimportantfloraandfauna,ecologicalcommunitiesand heritage places. You are responsible for ensuring your actions will not adversely affect:

FormoreinformationaboutthisActandtodownloadEnvironmentAustraliareferralforms,visitwww.environment.gov.au/epbc email: ciu@ea.gov.au or phone 1800 803 772.

2 Licence details2.1 Proposed licence details

• World Heritage properties

• Ramsar listed wetlands

• Nationallythreatenedflora&faunaandecologicalcommunities

• Internationallyprotectedmigratorybirds,and

• Commonwealth marine areas.

2.2 Proposed use of water

2.3 Extraction details

Tick one only:

Aquaculture Dairy shed water Domestic&stock

Environment Industrial or commercial Intensive animal husbandry (e.g. piggery)

Power generation Seepage&evaporationfromadam Urban water supply

Irrigation supply. Type of crop: _______________________________________________________________ Irrigation area: ________________________ Ha

Reuse.Approximatepercentageofwaterthatisconsideredtobeirrigationrun-off:________________ %

Other. Please specify: ____________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

Total annual volume: _________________________ ML

Please provide details of your proposed works (pumps and/or dams) for assessment purposes. Ensure all works are marked on the map described insection2.6withthesamereferencesasbelow.Detailsfortheworksaretobeenteredintosection3forpumps,and4fordams.

Pumps / dams Type of useExisting (E) or proposed (P)

Annual volume(ML)

Max daily pump capacity

(ML/day)

Maximum daily volume (ML)

Capacity(ML)

(if dam)

Wall height (m)(if dam)

Example 1 Dam 1

Irrigation E 10 n/a 2 20 3

Example 2 Pump 1

Domestic&stock

P 2.2 0.1 0.01 n/a n/a

2.4 Property where water is to be used(i) Attach a copy of the Land Title (the State Water Register requires evidence of ownership)

((ii) Volume and Folio numbers must be provided

Volume:

____________________________________________

Folio:

____________________________________________

Volume:

____________________________________________

Folio:

____________________________________________

Volume:

____________________________________________

Folio:

____________________________________________

Volume:

____________________________________________

Folio:

____________________________________________

2.5 Consent of occupier or crown land managerIfyouarenottheoccupierofthelandwheretheworksarelocated,orthelandiscrownland,printtheoccupierorcrownlandmanager’snamein capital letters and arrange for them to sign the consent below.

Name of occupier or crown land manager: ______________________________________________________________________________________________

Signature: _________________________________________________________________________________ Dated: _________ / _________/ ____________

2.6 Property details - where works are to be located

(i) Address: ___________________________________________________________________________________________ Postcode: ______________________

(ii) Attach a mapAttachasketchorphotocopyofalocalityplanonaseparateA4sheetshowingthelocationsofALLexisting&proposedworks(damsand/orpumps)ontheproperty.Labelexistingworksasnumber1,2,3etcandsiteofproposedworks.Showroads,accesstopropertyandmainfeaturesonpropertyas well as approximate distances to property boundaries or other features. Please ensure that the drawing is neat and clearly labelled.

If crown land: (ensure crown land manager consent is signed)

Crown allotment:

____________________________________________

Section:

____________________________________________

Parish:

____________________________________________

Example locality map

3.1 Pump detailsCopy this page and attach to application if more than three pumps are required.

Reference number on locality map:___________________________________________________________

Office Use Only

WRKWorkslocation(GDA94):

Easting:

E

Northing:

N

AMGzone(deleteasapplicable):

54 / 55

Pump description: _________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

Pump manufacturer: ______________________________________________

Serial number: _____________________________________________________Maximumflowrate:______________________________________________l/s

Workslocation(GDA94):

Easting:

E

Northing:

N

AMGzone(deleteasapplicable):

54 / 55

Pump description: _________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

Pump manufacturer: ______________________________________________

Serial number: _____________________________________________________Maximumflowrate:______________________________________________l/s

WorksLocation(GDA94):

Easting:

E

Northing:

N

AMGzone(deleteasapplicable):

54 / 55

Pump description: _________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

Pump manufacturer: ______________________________________________

Serial number: _____________________________________________________Maximumflowrate:______________________________________________l/s

Reference number on locality map: ____________________________________________________

Office Use Only

WRK

Reference number on locality map: ____________________________________________________

Office Use Only

WRK

3 Pump

4 DamCopy this page and attach to application if more than one dam is required.

Office Use Only

WRK

4.1 Proposed dam site & photographsProvidefivesetsofphotographsoftheproposeddamsite,takenfrom:

• upstream(A)

• downstream(B),and

• thewaterway/drainageline/gully/depressionetc.downstreamoftheproposedsiteatseverallocations,upto500mdownstreamortothenextmajortributary,whicheveristhelesser.

Thephotographsmustbelabelledwithsitedetailsanddistances.Theymustalsobeclear,focussedandshowsufficientdetailsoftheproposed site and other relevant sites. Please indicate on your locality plan where the photographs were taken from.

Locationofproposeddam(GDA94):

4.2 Water harvesting arrangementsIs the proposed site of the dam on a waterway with high ecological values or on a water course? Is the area/waterway a habitat for aquatic life? Yes No

IfSRWhasundertakenanon-siteinspectionofyourfarmdam,pleaseprovidedetailssuchasdateandnameofinspectingofficer.

Officer:__________________________________________________

Dated: _________ / _________/ __________

Areyouharvestingcatchmentrun-off? Yes No

4.3 Proposed new dam specificationsNote: Certain large dams or dams on waterways that have high ecological values will require technical advice from an engineer before approval is given and construction can begin.

Proposed total volume of dam at full supply level: _________________________________________________________________ megalitres

Proposed height of the dam wall from downstream toe to top of dam wall: __________________________________________ meters

Easting:

E

Northing:

N

AMGzone(deleteasapplicable):

54 / 55

4.4 Potential downstream / upstream impactsWill the proposed storage inundate a neighbouring property if it breaks? Yes No

Please identify the nearest downstream development and its approximate distance:

Township: ______________________________ km Occupied dwelling: ______________________ km Road crossing: _________________________ km

Railway crossing: _______________________ km Dam: ___________________________________ km

Please identify the nearest upstream development and its approx. distance: Dam: ___________________________________ km

Please list any environmental features upstream or downstream of the proposed dam: ___________________________________________________________

__________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

Please advise the distance to the closest high voltage power line either upstream or downstream of the proposed dam. _______________ m

When is the proposed construction period? From: _________ / _________/ ___________ To: _________ / _________/ ___________

4.5 Design & specifications for a typical gully damWorks Existing dam

Map: ______________________________________ Scale 1: ___________________________________________________

Catchment area: ____________________________________Ha Measured Observed

Soil type: clay Topography: flat Vegetation: pasture

loam gentle forest

sand hilly

other: _____________________________ steep

Details of existing dam (standard design format)

Embankmentcross-sectionelevationview(nottoscale)

a) Downstream height to crest: _____________________________ m b) Downstream batter length: ______________________________ m

c) Crest width: ____________________________________________ m d) Upstream batter length: _________________________________ m

e) Upstream height to crest: ________________________________m f) Core trench depth: _____________________________________ m

g) Core trench width: ______________________________________ m h) Embankment base width: _______________________________ m

i) Outlet pipe height: _____________________________________ m j) Outlet pipe downstream exposed length: _________________ m

k) Outlet pipe upstream exposed length: ___________________ m

Downstream batter slope (a/b): _____________________________m Upstream batter slope (e/d): _______________________________ m

Embankmentlongitudinalcross-sectionincludingspillway(nottoscale)

l) Embankment length: ____________________________________ m m) Spillway bottom width: _________________________________ m

n) Spillway depth from crest: _______________________________ m

Estimated storage capacity

Vol=0.4xMaxWaterDepthxSurfaceArea

0.4/1000x_____________(m)x_____________(m2)=______________(ML)

5.1 Details of engineer responsible for investigation, design & surveillanceSurname:___________________________________________________________ Given name:________________________________________________________

Company name:___________________________________________________________________________________________________________________________

Postal address:____________________________________________________________________________________________________________________________

Town:________________________________________________________________________________________________ Postcode:_______________________

Telephone: ______________________ Mobile: _________________________ Email: ________________________ Fax: ____________________________

Eligibility for Institute of Engineers Australia membership:

No Yes Membership No. ________________

Qualifications&experience:________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

5.2 Details of engineer responsible for supervising dam constructionSurname:___________________________________________________________ Given name:________________________________________________________

Company name:___________________________________________________________________________________________________________________________

Postal address:____________________________________________________________________________________________________________________________

Town:________________________________________________________________________________________________ Postcode:_______________________

Telephone: ______________________ Mobile: _________________________ Email: ________________________ Fax: ____________________________

Eligibility for Institute of Engineers Australia membership:

No Yes Membership No. ________________

Qualifications&experience:________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

5 Large or on-stream damTo be completed by the engineer responsible for supervising the construction of the dam where:

• Theproposeddamwillbelocatedonawatercourse,orifthedamfitsthecriteriaforabigdam;

• Theoff-streamdamhasawallheightof5metresormoreandacapacityof50megalitresormore;

• Theoff-streamdamhasawallheightof10metresormoreandacapacityof20megalitresormore;

• Theoff-streamdamhasawallheightof15metresormoreregardlessofcapacity.

5.3 Contractor details for dam constructionSurname:___________________________________________________________ Given name:________________________________________________________

Company name:___________________________________________________________________________________________________________________________

Postal address:____________________________________________________________________________________________________________________________

Town:________________________________________________________________________________________________ Postcode:_______________________

Telephone: ______________________ Mobile: _________________________ Email: ________________________ Fax: ____________________________

5.4 Proposed dam’s technical featuresPlease provide details for the proposed dam.

Type of Dam:Earthfill:

Homogeneousearthfill Zonedearthfill

Rockfill: Earth&Rockfill Rockfill Rockfillwithimperviousface

Concrete / masonry: Arch Buttress Gravity

Other details:Proposed height of dam wall (from downstream toe to top of wall): ___________________________________________m

Capacity of dam at full supply level: ______________________________ (ML)

Surface area of water: __________________________________________ (M2) Spillway capacity: __________________________________________(ML/day)

Designflood(AEP)1in:_______________________________________years

Hazardcategory

Very low Low Significant

High A High B High C Extreme

Engineer’ssignature:_________________________________________________________________________________ Dated: ______ / ______/ __________

Outlet pipe:diameter: _____________________________(mm) Upstream valve: ___________________________ Downstream valve: __________________________

6 NotesNotes to assist you to complete this application form.

1. SouthernRuralWater(SRW)stronglyrecommendsthatyouspeaktooneofourassessmentofficersbeforesubmittingthisapplication.

2. Assessing&determiningtheapplication

a. Iftheproposalrelatestoacommercialorirrigationusedam,SRWwillundertakeawateravailabilityassessmentforthecatchment.Fees apply in these circumstances.

b. Ifyourapplicationrelatestoadamlocatedonawaterwayorifthedamisforacommercialorirrigationuse,yourapplicationwillbe referred to other agencies (e.g. DSE) for comment.

c. You may be required to submit an environmental assessment report as part of your application.

d. Ifyourapplicationrelatestoadamthatwillbegreaterthan10megalitresinsize,youwillneedtogivewrittennoticetooccupiersoflandupstream and downstream of the site. You will also have to advertise the proposal. SRW will give you more information if this applies to your application.

e. Ifyourapplicationrelatestoadamlessthan10megalitresincapacityandlocatedinanenvironmentallysensitivearea,youmayberequired to advertise the proposal.

f. Inmostinstances,forlargedams,thedammayneedtobedesignedandtheconstructionsupervisedbyaqualifiedEngineer.

3. ContactDetails:pleaseprovideyourpostaladdressandphonenumbers.Ifyouareacurrentcustomer,providedetailsofyourlicencenumber.

4. Use (Section 2.2): Only one proposed purpose for the water can be selected. The descriptions below may help you select the correct one.

Ifyourequirealicencethatinvolvesusingwaterformorethanonepurpose,youwillnedaseparatelicenceforeachpurpose.

5.

6. Works location (Section 2.6)

a. A copy of title is essential to provide details of the location of the property on which the dams and or pumps are located. Ensure Volume &Foliodetailsarecompleted.

b. Provide a locality plan of the proposed works site including (Australian Map Grid Reference) Easting and Northing coordinates for the dam. ThiscanbetakenfromtheMelwaysorVicRoads(onlargerproperties),orcanbedeterminedwiththehelpofyourlocalSRWAssessment Officerifunknown.Thisplanshouldalsoshowthelocationofexistingdamsandpumpsontheproperty.

c. AMelwaysorVicRoadsreferenceshouldincludemapnumberandcoordinates.Forexample-Melwaysmap120E5.

7. Wateruselocation(Section2.4):Providedetailsoflandonwhichthewateristobeused.Thesedetailscanbefoundonyourpropertytitle. Ifpossible,pleaseattachcopiesofalltitlesconcernedincludingthesegmentshowingthecurrentownership.EnsureVolume&Foliodetails are completed on the application form. Crown description of the land can also be obtained from your Council rate notice.

Use of water Description

Domestic and stock Domesticandstockuse-aswellasgeneralnon-irrigationfarmuse.

RefertoSRW’swebsiteat www.srw.com.auforafulldefinitionofDomestic&Stockuse.

Irrigation Irrigation-aswellasdomesticandstockuse,dairyuse,andgeneralnon-irrigationfarmuse

Dairy Dairyuse-aswellasdomesticandstockuseandgeneralnon-irrigation farm use

Intensive animal husbandry Intensiveanimalhusbandryuse-aswellasdomesticandstockuseandgeneralnon-irrigationfarmuse

Industrial or commercial Industrialorcommercialuse-aswellasdomesticandstockuse

Environment Environmental use

Urban water supply Urban water supply

Power generation Power generation

Aquaculture Aquacultureuse-aswellasdomesticandstockuse

Seepage and evaporation Seepage and evaporation

8. Photographsofdamsite(Section4.1):Itisessentialtoprovide5setsofphotographsshowingtheproposeddamsite,upstreamofthesiteand downstream of the site.

9. Catchment. In what catchment is the proposed dam?

a. Providethenamethewaterwaythedamistobelocatedon,orthewaterwaythatwaterwouldflowintoifitwerenotcapturedinyourdam(Section 2.1)

b. Ifpossible,identifythecatchmentareaoftheproposeddam.Thiscannormallybecalculatedfromatopographicalmap.Inadditiondescribethegeneraltopographyofthearea(Section4.5).

c. Ifthestreamisunnamed,thenindicatethisfollowedbythenameofthestreamthatthewaterwouldnormallyflowinto.Forexample–waterwouldnormallyflowintoanunnamedgullythatthenflowsintoStringybarkCreek.

10. Proposeddamspecifications(Section4.3):Theanswerstothisquestionhelpustodeterminethesizeofthedam.Asaminimum,youshouldinclude the approximate proposed total volume of dam at full supply level and the proposed height of the dam wall from downstream toe to the top of dam wall.

11. Potentialimpacts(Section4.4):UsedinconjunctionwithSection5todeterminewhetherthedamcouldbepotentiallyhazardousifafailureoccurs. Please identify:

a. Upstream,butmoreimportantlydownstreamdevelopments.Thisincludesroads,buildings,townshipsandanyothersignificantinfrastructure.

b. Indicate if water in the proposed dam will inundate neighbouring property if breached.

c. Indicatetheapproximatedistancetothenearesthouseandroadorothersignificantdevelopmentsbelowthedam.

These should also be drawn on your map of the works location.

12. Large or onstream dam (Section 5): To be completed by the engineer responsible for supervising the construction of the dam where:

a. Theproposeddamwillbelocatedonawatercourse;

b. Theoff-streamdamhasawallheightof5metresormoreandacapacityof50megalitresormore;

c. Theoff-streamdamhasawallheightof10metresormoreandacapacityof20megalitresormore;

d. Theoff-streamdamhasawallheightof15metresormoreregardlessofcapacity.

This section may need to be completed once it is determined that your proposal needs to be designed (Section 5.1) and construction supervised (Section 5.2) by an Engineer. If you are submitting engineering plans, please attach 5 copies. SRW may request that the applicant engage their engineer to produce a Surveillance Program and Emergency Response Plan prior to issuing a construction licence. These plans must also be reviewed at least every 5 years.

13. Environmentalissues(Section4.4):Inordertoassesswhethertheproposeddamwillimpactonsensitivemattersofenvironmentalsignificance,pleaseidentifyallknownorobservedwetlandsandanyfloraorfaunaissuesatthedamsiteorinthegeneralarea.

14.Proposeddesign&dimensionsofthedam(Section5.4):Thissectionshouldbecompletediftheproposeddamistobelocatedonawaterwayorisagullydam.Iftheproposalrelatestoacatchmentdamthatwillbeusedforcommercialorirrigationpurposes,pleaseprovideasketchoftheproposed design with all dimensions including depth.

15. Licencestotakeandusewaterbelongtothepersonandnottheproperty.ThereforeSRWisunabletoformallyregisterinterestsbyanythirdparty,including mortgages.

16. Application fees received with this application may be non refundable or only partially refundable should you decide to opt out of the process at anytimeafterwereceivethisapplicationform.WerecommendthatyoudiscussthisproposalwithanSRWAssessmentOfficerbeforesubmittingyour application.

Southern Rural Water’s Privacy StatementSouthern Rural Water (SRW) values and protects the personal and private information we collect from customers or applicants as part of our businessactivitiesandresponsibilities.Wehavealwaysdemonstratedastrongcultureofprotectingtheconfidentialityofthisinformation.Ourpolicy is to collect only the information we need to conduct our business or to provide a service to customers. Essential personal information suchasacustomer’sname,addressortelephonenumberisonlyreleasedoutsideSRWwiththecustomer’sconsentorifreasonablyrequiredforrelatedgovernmentbusiness,suchastheprocessingofcouncilratesorifrequestedbylawfulorders.Asourresponsibilitiesdemandsustainablemanagementofwaterresourcesandthenurturingofthebusinesses,communitiesandenvironmentsthatsupportanddependonthem,SRWadoptsanopen,transparentapproachtothemanagementofwaterresourcesandentitlements.Webalancethedisclosureofcustomerrelatedwaterentitlementswiththenon-disclosureofpersonalinformation.SRWtakesallreasonablestepstoensurethatthemanagementofallpersonalinformation collected and disclosed complies with the Water Act 1989 requirements and privacy principles. All customers can access their own information.

Privacy ComplaintsIfyouconsiderthatyourprivacyhasbeenbreachedorinterferedwith,youshouldcontacttheSRWPrivacyOfficeratPOBox153,MaffraVic3860, or phone SRW on 1300 139 510.

More informationIfyouwanthelpwithyourapplicationormoreinformationonSurfaceWaterLicences,visitourwebsiteatwww.srw.com.au or phone Southern Rural Water on 1300 139 510andaskfortheSurfaceWaterFactSheetorspeaktoanAssessmentOfficer.

DisclaimerSouthern Rural Water will use the information provided in this Application Form to act on and/or make a Surface Water Licence decision. Should this informationbeincorrectorchange,wemaytakestepstorevokeanylicencegrantedandrequireyoutosubmitanewapplicationtogetherwiththeapplicable fee.

Annexure 6Copy this annexure and attach to application if there are more applicants than provided for.

Please print name(s) in full and in capital letters. Illegible applications will be returned. All applicants must sign. All notices will be sent to the postal addressofthefirstnamedpartyintheStateWaterRegister.

I/we the undersigned certify that the information provided in this application is true and correct.

I/we understand that this information may be referred to other organisations and/or advertised as part of the application and assessment process or released if reasonably required by government business, requested by lawful orders, or in the public interest; particularly in regard to open disclosure of generally collected water entitlements.

If applicant is a company:

Name of company:___________________________________________________________________________________ ABN:___________________________

Given name(s):

________________________________

Surname:

________________________________

Signature:

________________________________

Position:

________________________________

Given name(s):

________________________________

Surname:

________________________________

Signature:

________________________________

Position:

________________________________

Name of company:___________________________________________________________________________________ ABN:___________________________

Given name(s):

________________________________

Surname:

________________________________

Signature:

________________________________

Position:

________________________________

Given name(s):

________________________________

Surname:

________________________________

Signature:

________________________________

Position:

________________________________

Dated: ____________ / _____________/ __________________If there are more than two additional applicant companies, please copy this Annexure and attach to application. All applicants must sign the declaration.

Notethattheperson(s)whosignsonbehalfofacompanymustbeauthorisedtodoso,forexample,acompanysecretaryordirector.Southern Rural Water will not accept liability if this form is signed by a person who is not authorised to do so.

Individual applicant(s):

Given name(s):

____________________________________________

Surname:

____________________________________________

Signature:

____________________________________________

Given name(s):

____________________________________________

Surname:

____________________________________________

Signature:

____________________________________________

Given name(s):

____________________________________________

Surname:

____________________________________________

Signature:

____________________________________________

Given name(s):

____________________________________________

Surname:

____________________________________________

Signature:

____________________________________________

Given name(s):

____________________________________________

Surname:

____________________________________________

Signature:

____________________________________________

Given name(s):

____________________________________________

Surname:

____________________________________________

Signature:

____________________________________________

Dated: ________ / _________/ ______________

If there are more than six additional applicants, please copy this Annexure and attach to application. All applicants must sign the declaration.