VP Form 1193
APPLICATION FOR POPULOUS PLACE PERMIT – VERMIN CONTROL
(Section 130 Firearms Act 1996)
APPLICANT’S LICENCE DETAILS
Applicant’s Licence No.:
Expiry Date of the licence:
/
/
APPLICANT’S DETAILS
Organisation Name: ____________________________________________________________________________
Person Surname: ______________________________________________________________________________
Given Name(s): __________________________________________________Date of Birth: ______/______/______
Business/Residential Address: ____________________________________________________________________
_____________________________________________________State: _____________ Postcode: _____________
Postal Address: ________________________________________________________________________________
_____________________________________________________State: _____________ Postcode: _____________
Telephone: (H) ___________________________ (W) ________________________ (M) ______________________
Email address:
ACTIVITY DETAILS AND SITE PLAN
(Documents need to be provided by the land owners giving permission to the applicant and any other affiliated licence holder’s permission to
conduct the activity on the land, and highlighting the need for the activity to occur)
Land owners name i.e. Organisation or Person Name:
_____________________________________________________________________________________________
Specific address or location of the shoot: ____________________________________________________________
What is manufactured/produced or activity is undertaken at the property/location?
_____________________________________________________________________________________________
Contact name at location: _________________________ Contact Number: ________________________________
Date/s of the activity (if ongoing please indicate timeframes): _________ ___________________________________
Times of activity: START: ________________________________ FINISH: _________________________________
Type of vermin: ________________________________________________________________________________
Outline other methods of eradication that have proved unsuccessful at the location: ___________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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VP Form 1193
NOTE: An inspection of the site will need to be carried out by the Divisional Firearms Officer or his /her delegate to
ensure that the activity can be conducted safely at the location.
a) If the site has not previously inspected, the application is required 28 working days prior to the requested dates.
b) If the site has been previously inspected within the last two years, the application is required 15 working days
prior to the requested days.
Has property/location been inspected by Victoria Police for the requested activity
YES
NO
YES
NO
within the last two years? (if changes have occurred it will need to be re-inspected)
Have there been any known infrastructure changes to the location within the last two years?
Please attach a site plan of the location where the activity will take place (attach photographs if available)
The site plan is not required to be to scale, however it should indicate the following:

The position from where the shots are to be fired;

The direction in which they are to be fired;

The distance from any neighbouring properties; and

Notification of the type of buildings and public thoroughfares in the vicinity.
The Divisional Firearms Officer will refer to these documents when conducting their inspection and assessment
of the site.
DETAILS OF FIREARM LICENCE HOLDERS REQUIRED TO PARTAKE IN THE ACTIVITY
Name: _____________________________________ Licence Number: _____________________________
Name: _____________________________________ Licence Number: _____________________________
Name: _____________________________________ Licence Number: _____________________________
FIREARM DETAILS
CATEGORY
TYPE
ACTION
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CALIBRE
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VP Form 1193
SAFETY ISSUES
Do you have documented safety operating procedures?
YES
NO
If ‘Yes’, have these been provided to Victoria Police in the past 12 months?
YES
NO
If answered ‘No’ to either of these questions, you must supply a copy of your current safety operating
procedures, which include the use of firearms, with this application.
PUBLIC LIABILITY
Do you have public liability insurance that covers this activity, specifically
YES
NO
YES
NO
the use of firearms?
If ‘No’ does the land owner have the insurance to cover you (the applicant)?
Evidence of this will need to be provided with this application.
______________________________
______________________
Signature of Applicant
Date of Application
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VP Form 1193
APPLICATION CHECKLIST
Have you provided the name of the land owner i.e. organisation/person seeking
permission to shoot in a populous place?
YES
NO
control and how often it will need to be completed?
YES
NO
Has this letter been signed by the Chief Executive Officer or equivalent?
YES
NO
YES
NO
need on their licence?
YES
NO
Are all shooters licensed in the category of the firearms to be used?
YES
NO
YES
NO
YES
NO
Have you provided a letter of permission/evidence of contract from the land owner of the
property/location where the shooting will be taking place, outlining the need for vermin
Have you provided a site plan indicating where shots are to be fired and in
which direction?
Do all individuals required to partake in the shooting have vermin control as a genuine
Have you provided safety procedures that outline operating procedures of the
business/individual during the course of the activity? (or within the last 12 months)
Have you provided evidence of public liability insurance, specifying the use of
firearms? (If own firearms are not being used, insurance will need to cover the use of another
individual’s firearms).
Send your completed application to: Licensing & Regulation Division, GPO Box 2807, Melbourne VIC 3001.
Contact Licensing &Regulation Division on 1300 651 645, between 8.30am-4.30pm, Monday to Friday or email
[email protected]
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