1. Application Type (Tick appropriate boxes)

Size: px

Start display at page:

Download "1. Application Type (Tick appropriate boxes)"

Martin Elliott
5 years ago
Views:

1 DAGEROUS GOODS ACT 1985 DAGEROUS GOODS (HCDG) REGULATIOS 2016 September 2010 WORKSAFE VICTORIA APPLICATIO FOR A LICECE TO ACCESS HIGH COSEQUECE DAGEROUS GOODS (HCDG) Office use only checklist (please circle) Please refer to General Information and Instructions at the end of this form for guidance on completing and submitting this application. 1. Application Type (Tick appropriate boxes) I wish to apply for: Is part 1 A ew Licence to Access High Consequence Dangerous Goods (HCDG) Renewal of my Licence to Access High Consequence Dangerous Goods (HCDG) Licence o. Date of Expiry Amendment to my Licence to Access High Consequence Dangerous Goods (HCDG) Licence o. Date of Expiry Please specify amendment details A Replacement Licence to Access High Consequence Dangerous Goods (HCDG) because my licence has been Lost Stolen Destroyed Other (please specify) Licence o. Date of Expiry I wish to apply for the following licence(s) Manufacture HCDG to manufacture, store use, dispose of, handle and supply of HCDG Import HCDG into Victoria from another country, to handle, supply, transfer and sell and store HCDG at any specified place Export HCDG from Victoria to another country, to handle, supply, transfer and sell and store HCDG at any specified place Handle or store HCDG at any specified place Handle, supply, transfer, store and sell HCDG at any specified place Transport and handle HCDG Use, handle, dispose of and store HCDG at any specified place Primary Producer to store, use, dispose of and handle HCDG used or intended to be used in connection with the primary producer s business (not for the purpose of transfer or sale) (B: Can transport limited amounts in a one stop journey) If required, has endorsement/s been ticked? 2. Applicant Details a. Complete if the applicant is a atural Person (must reside in Victoria) Family ame Given ames Is part 2 (a) Trading As (if applicable) Residential Address (must be in Victoria) Details verified to ID? Postal Address (if different) Page 1 of 6

2 2. Applicant Details (continued) Telephone (BH) Telephone (AH) Mobile ID Ref. _ Facsimile Date of Birth _ TRIM o. _ b. Complete if the applicant is a Body Corporate (must carry on a business in Victoria that relates to HCDG) Full Legal ame of Organisation Is part 2 (b) Trading As AB AC Details verified to ID? Registered Address (must be in Victoria) Postal Address (if different) ID Ref Principal Business Address (relevant to the handling of HCDG) Contact Person ame Registered Telephone TRIM o. Registered Facsimile 3. Location / Construction / Operation of the HCDG Address of Premises / Place to be Licensed Location details Premises Telephone This location is a Mine Mine Licence o. Quarry Work Authority o. 4. Lawful eed Provide a description of the commercial, agricultural, industrial or other process or activity undertaken or proposed to be undertaken. Is part 4 Lawful need satisfied? Page 2 of 6

3 5. Type of HCDG to be Accessed (add sheet if more products required) ame Eg. Ammonium nitrate U o. (if applicable) ame U o. (if applicable) Is part 5 ame and U o. of HCDG shown? 6. omination of Person with Responsibility for Security of the HCDG (Complete this section if the applicant is a body corporate) Family ame Given ames Is part 6 Required? Position Contact Telephone Mobile Date of Birth I hereby consent to the nomination as the person responsible for security ominated Person s Signature Date ID Form ID# Identification A completed and verified Identification Form atural Person, for the nominated person (tick one) is enclosed with this application; or has been previously submitted Police Check and ASIO Security Assessment a completed Consent to Conduct Police Check and ASIO Security Assessment for the nominated person is enclosed with this application Police Check & Security Assessment Suitable Person Ref: 7. omination of Director(s) or Person in the Body Corporate s Management (Complete this section if the applicant is a body corporate which is not a public company) Family ame Given ames Is part 6 Required? Position Contact Telephone Mobile Date of Birth I hereby consent to the nomination. ominated Person s Signature Date ID Form ID# Identification A completed and verified Identification Form atural Person, for the nominated person (tick one): is enclosed with this application; or has been previously submitted Police Check and ASIO Security Assessment a completed Consent to Conduct Police Check and ASIO Security Assessment for the nominated person is enclosed with this application Police Check & Security Assessment Suitable Person Ref: OTE: To nominate more than one Director or person, please provide the above details separately. Page 3 of 6

4 8. Consent and Declaration Consent I consent to the collection, use and disclosure of personal information by WorkSafe Victoria (WorkSafe) for the purpose outlined in the section headed Collection of Personal Information on this form. Declaration I,, being the applicant for a High Consequence Dangerous Goods Licence under the Dangerous Goods (HCDG) Regulations 2016 declare that; OR I have not ever been found guilty of an offence under any relevant occupational health and safety or dangerous goods legislation. I have been found guilty of an offence under relevant occupational health and safety or dangerous goods legislation and provide the details of every such findings as follows including - when and where it occurred, and details of the offence in respect of which it occurred, and a brief description of the circumstances of the offence OR I have not ever previously had a licence or approval suspended or cancelled under any relevant occupational health and safety or dangerous goods legislation. I have previously had a licence or approval suspended or cancelled under a relevant occupational health and safety or dangerous goods legislation and provide details of the suspension or cancellation (stating which) as follows I,, declare that all the information contained in and accompanying the application is, to the best of my knowledge, true and correct. I understand that it is an offence under the Dangerous Goods Act 1985 to provide false or misleading information. Please sign within the box using black pen Signature of Applicant WARIG: The provision of false and misleading information is an offence under the legislation Date D D M M Page 4 of 6

5 9. Checklist Use this checklist to ensure that your application is complete: All Applicants Checklist Complete? Application completed, signed, witnessed and dated Appropriate payment and details provided Provide attachments if not previously submitted (see details below) Attachments required (if not previously submitted) All applicants Security plan Certified copy of current equivalent interstate licence (where applicable) All Body Corporates Completed and verified Identification Form - atural Person, for the nominated person responsible for security Completed Consent to Conduct Police Check and ASIO Security Assessment, for the nominated person responsible for security Completed Identification form on-individual and attachments Additional information required if the Body Corporate is not a public company If nominating more than one Director or management person, attach sheet of paper providing details Completed and verified Identification Form atural Person, for each nominated person Completed Consent to Conduct Police Check and ASIO Security Assessment for each nominated person Individual Applicant Completed and verified Identification Form atural Person Completed Consent to Conduct Police Check and ASIO Security Assessment (ot required if equivalent interstate licence is held). OTE: Incomplete applications or applications not accompanied by the required documentation may not be processed. 10. Payment Options Please see WorkSafe website for schedule of High Consequence Dangerous Goods Licence fees Paying by mail I wish to pay by: Cheque OR Money order Make cheque/money order payable to WorkSafe Victoria. Fee paid? Receipt o? Paying by credit card I wish to pay by credit card. Please charge payment of $ to my: MasterCard Visa Card o. Expiry Date Receipt date? / / Cardholder ame Signature Amount $ Page 5 of 6

6 11. General Information and Instructions 1. WorkSafe cannot process applications from a person whose identity has not been verified. If you have not previously done so, you must complete and submit an Identification Form atural Person / Identification Form on-individual with this application. 2. WorkSafe cannot issue a licence to a natural person, under the Dangerous Goods (HCDG) Regulations 2016 if it does not consider the applicant a suitable person to hold the licence. ou must complete and submit a Consent to Conduct ational Police Check and ASIO Security Assessment form with this application. Collection of Personal Information Personal and/or health information collected by WorkSafe in connection with this application will be used for the purpose of assessing this and any associated applications. The information collected may also be used in the administration and enforcement of legislation administered by WorkSafe, including the Occupational Health and Safety Act 2004 and the Dangerous Goods Act 1985, the administration and evaluation of WorkSafe s programs generally and for law enforcement functions and legal proceedings. WorkSafe may disclose personal and/or health information for public health and safety purposes. It may disclose that information to other government agencies, including emergency services, law enforcement and security agencies, including Victoria Police. WorkSafe may also disclose personal and/or health information to its contractors and agents, to a court or tribunal, to other regulatory agencies and to any person authorised to whom relates, or by law, to obtain it. WorkSafe may disclose a person s licence status to employers, prospective employers or members of the public who wish to check this status. Collection of you personal and/or health information may be required by the Occupational Health and Safety Act 2004 or Dangerous Goods Act 1985 and associated regulations. If you do not provide any or all of the information your application may not be accepted or processed. ou may access your personal information held by WorkSafe by contacting the Freedom of Information and Privacy Team. WorkSafe s Privacy Policy is available at worksafe.vic.gov.au. Further Information Telephone Facsimile licensing@worksafe.vic.gov.au Visit our website worksafe.vic.gov.au Submit your completed application form to: WorkSafe Victoria Licensing Branch GPO Box 4293 Melbourne Vic 3001 WorkSafe Victoria is a trading name of the Victorian WorkCover Authority FOR693/04/06.16 Page 6 of 6

Application for criminal history screening prescribed notice (yellow card)

Department of Communities, Child Safety and Disability Services Application for criminal history screening prescribed notice (yellow card) For use by a disability services funded on behalf of a person