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You are here: Agriculture » Farming and Management » Chemical Use » Agricultural Chemical Use » Bait Use and 1080 » Bait User Declaration Form

Bait User Declaration

This declaration MUST be completed by the bait user and co-signed by an authorised or 1080 accredited retailer prior to bait purchase

Bait user's name:
Bait user's 1080 authorisation type (tick one):	Licence Number:
ACUP with 1080 endorsement
COL with vermin destroyer endorsement
LTUP authorising the use of pesticides formulated for pest animal control
Bait user's address:
Address of property/land where baits will be laid (if different to above):
Pest species that is targeted for control (tick):	rabbit   fox   wild dog   feral pig
Area to be treated:	hectares
Dates during which bait will be present on land (dd-mm-yy):	to

 

Agent's 1080 authorisation type (tick one):	Licence Number:
ACUP with 1080 endorsement
COL with vermin destroyer endorsement
LTUP authorising the use of pesticides formulated for pest animal control

 

User Declaration:

I ……………………………………………………… (user's name) certify that:

• I am the holder of the above described authorisation to purchase and use 1080 pest animal bait
• I have undertaken a risk assessment as described in the Directions for the Use of 1080 Pest Animal Bait Products in Victoria and have determined that I have a genuine need to use 1080 pest animal bait
• I agree to use the product in accordance with the directions on the product label and the Directions for the Use of 1080 Pest Animal Bait Products in Victoria.

Signature of user: …………………………………………………………………………… Date:……………

 

Supplier Declaration:

I ……………………………………………………… (name of retailer) certify that:

• I have sighted the user's/agent's authorisation to purchase and use 1080 pest animal bait and have supplied the user/agent with …………… (insert units or volume of product supplied) on …………… (dd-mm-yy)
• I will retain a copy of this co-signed declaration for a minimum period of 3 years.
• Invoice Number:…………………………………………………………………
• Name of Store:…………………………………………………………………
• Perishable Bait Manufacturer DHS Licence Number (if applicable):……………………………………………………
• Agsafe Guardian Premises Accreditation Number (if applicable):……………………………………………………
• Agsafe 1080 Training Number:……………………………………………………
• Date of last Agsafe course: ……………………………………… (dd-mm-yy)

Signature of Supplier: …………………………………………………………………………… Date:……………

 

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