|Personal Details | |
|Mr/Mrs/Ms | |First Name | |Other Given Names | |Family Name |
| | | | | | | |
|Date of Birth | |Aged 12–17yrs ? | |Gender | |Customer No. or Game Licence No. |
| | |No / Yes |If ‘Yes’, no fee applies. |Male / Female | | |
|Postal Address | |
|Flat / Unit / House Number | |Street / Road Name or PO Box / RMB No. |
| | | |
|City / Suburb / Town | |Post Code |
| | | |
|Residential Address | |(If different from above). |
|Flat / Unit / House Number | |Street / Road Name. |
| | | |
|City / Suburb / Town | |Post Code |
| | | |
|Which Game Species ? | |Which Licence Term ? | |
|Tick One |Tick One |Short-Term or |Long Term |
|( Deer (Stalking) | | |
|( Deer (Stalking & Hounds*) |( $50.10 (or $25.00 concession) |( $150.30 (or $75.10 concession) |
|( Game Birds, including Duck* |Valid to 31 December 2013 |Valid to 31 December 2015 |
|( Game Birds, not including Duck | | |
|( Deer (Stalking) & Game Birds, including Duck* | | |
|( Deer (Stalking & Hounds*) & Game Birds, including Duck* |( $75.10 (or $37.50 concession) |( $225.30 (or $112.60 concession) |
|( Deer (Stalking) & Game Birds, not including Duck |Valid to 31 December 2013 |Valid to 31 December 2015 |
|( Deer (Stalking & Hounds*) & Game Birds, not including Duck | | |
|To claim the concession rate, you must prove