Registration of interest for the right to
apply for an aquifer access licence
This application form is to be submitted to lodge a Registration of Interest (RoI) to obtain the right to apply for an
aquifer access licence under the Controlled Allocation Order (Various Groundwater Sources) 2017 (order).
Read the Terms and Conditions
Prior to making a RoI Application, applicants are advised to read the Terms and Conditions set out in Schedule 2 of
the order. The RoI process will be conducted in accordance with the Terms and Conditions. The Terms and
Conditions set out the rights and obligations of each participant. By making an RoI Application, an applicant is
accepting the Terms and Conditions.
Read the Guide to complete this application form
You are also advised to read the Guide to the registration of interest for the right to apply for an aquifer access
licence which includes more information on how to complete this form.
How to pay application fees
The application fee ($150) can be paid:

by credit card. If you wish to pay by credit card, please check the box below at A17. A DPI Water officer will
then call you on the number provided to take your payment over the phone; or

by enclosing a cheque or money order for the application fee made out to the “NSW Department of Primary
Industries, Water” when posting the form.
Please do not provide your credit card details to us by post or email as DPI Water cannot guarantee the security of
your details through these channels.
Application fees are exempt from GST.
How to submit an application
The completed and signed RoI application form must be posted to DPI Water:
Controlled Allocation Officer
Level 11 Macquarie Tower
Locked Bag 5123
Parramatta NSW 2124
Privacy note
The personal information you provide in this form will be treated in accordance with the Privacy and Personal
Information Protection Act 1998, under which you have rights of access and correction. Your personal information
will be used by DPI Water for assessing and processing your RoI Application or in connection with the application
for, or operation of, any access licence granted following the RoI process and may be disclosed to State or
Commonwealth public authorities, including WaterNSW, and other parties: (i) for any of the above mentioned
purposes; (ii) for research related purposes; or (iii) as required by law. It may be used from time to time to contact
you about services DPI Water provides. Further information regarding privacy can be obtained from the NSW
Department of Industry website at http://www.industry.nsw.gov.au/privacy.
OFFICE
USE
ONLY
Fee paid: $
Customer receipt number:
Officer signature:
Date:
Application number:
Acceptance date:
Document number: WMAF014 | April 2017
Office Stamp
Page 1 of 3
Registration of interest for the right to apply for an aquifer access licence
SECTION A: Applicant details
List all applicants. Photocopy/print multiple copies of the first page of this form if more than one applicant.
Applicant
A1 Title (Mr, Mrs, Ms)
A3
A2
Surname
Given name(s)
A4 Corporation
name (if applicable)
A5
ACN (if applicable)
A7
Address
A8 Town
A6 Position
A9
State
A10 Postcode
A12
Phone
A14
Fax
A16
If more than one applicant specify total number of applicants
A17 (optional)
A13
A15
held (if applicable)
A11
Country
Mobile phone
Email
Request for DPI Water officer to call you to pay your application fee by credit card
☐
SECTION B: Nominated price per unit share of water
The minimum price for the right to apply for an access licence per unit of access licence share component
(“unit share”) of water in each water source is set out in Schedule 1 of the Order. You cannot nominate a price
lower than the relevant minimum price.
Nominate the price per unit share of water you are willing to pay for
the right to apply for an access licence
B1
$
(Insert whole numbers only)
SECTION C: Nominated number of unit shares to purchase
Please nominate the unit shares in an access licence you are seeking the right to apply for.
Nominate the number of unit shares of water you want to purchase
C1
unit shares
(Insert whole numbers only)
Name of water source
C2
Choose an item.
Zone (if applicable)
C3
Choose an item.
Name of town nearest to where you propose to take water
C4
(This will assist in determination of which local office will manage any application for an access
licence)
Document number: WMAF014 | April 2017
Page 2 of 3
Registration of interest for the right to apply for an aquifer access licence
SECTION D: Acknowledgement of applicant(s)
Each applicant must sign the completed RoI Application form. If there are more applicants than spaces on this form
for individuals to sign then after the form has been completed the entire form must be photocopied or printed and
signed by each applicant.
I/We, the undersigned applicants, acknowledge and represent that:

I/We accept and agree to the Terms and Conditions
For RoI Applications made by individuals:
Name
Signature
Date
Name
Signature
Date
Name
Signature
Date
For RoI Applications made by a corporation: Executed for and on behalf of the applicant in accordance with
section 127 of the Corporations Act 2001 (Cth) (if a company) or by its duly authorised officer (for other types of
corporation):
Name of company/corporation
Position of signatory
company director
company secretary
duly authorised officer
(Tick the appropriate box/select the correct option)
Name of signatory
Position of signatory
Signature
company director
Date
company secretary
(Tick the appropriate box/select the correct option)
Name of signatory
Document number: WMAF014 | April 2017
Signature
Date
Page 3 of 3