Purchaser
name
Declaration by purchaser at point of retail
sale of hormonal growth promotants
Original signed copy to be retained by the Supplier for two years for audit purposes. Duplicate to be retained by the Purchaser.
A hormonal growth promotant (HGP) must not be supplied to a person unless the completed and signed declaration in this form
is first provided to the supplier (regulation 48 of the Agricultural and Veterinary Chemicals Code Regulations 1995).
Contact
phone no.
Email address
Contact
address
I, being the owner or authorised representative of the owner responsible for the husbandry of the livestock on the property/ies
assigned the Property Identification Code (PIC) number(s) detailed below declare that I have today purchased from:
Supplier
name
Contact
phone no.
S
n
n
Supplier
address
upplier
otification
o.
The following HGP products that will be implanted into cattle and kept at the property associated with the following PIC
number(s):
PIC number
Total quantity of doses
HGP brand and type
Batch number
And that I will permanently identify all treated animals by using the prescribed ear punch mark at the time of their implantation in
accordance with the following requirements:
1. Only the approved ear punch available from authorised retailers of HGPs may be used for applying this prescribed earmark.
2. The prescribed ear punch mark shall be in the form of an equal sided triangle with sides of 20 millimetres.
3. The mark is to be applied so as to leave a space on all sides within the margin of the ear.
4. The ear shall be marked in accordance with state/territory law.
5. If an animal has previously been treated with HGPs and has been ear punched with the prescribed mark, there is no
requirement to again identify the animal with this mark.
I recognise that supply and/or use of HGPs other than in accordance with the requirements of relevant state/territory legislation
may constitute an offence under that legislation.
I acknowledge that a copy of this form will be retained by the above supplier and that the information on the form will be
disclosed to the Australian Pesticides and Veterinary Medicines Authority (APVMA). This information may also be disclosed to
other government agencies or persons involved in the beef industry and may be used in the regulation or management of the
supply and use of HGPs and of cattle treated with HGPs. Personal information will be managed in accordance with the APVMA
Privacy Policy, available at apvma.gov.au/node/59876.
I acknowledge that it is an offence to knowingly provide false or misleading information (section 146 Agricultural and Veterinary
Chemicals Code Act 1994) and giving false or misleading information is a serious offence (section 137.1 Criminal Code Act
1995).
_____________________________________________________________________________________________________
Purchaser name Purchaser signature Date
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