Licence to Store Explosives - Corporate by alendar


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									                                                           Explosives Act 1999
                                                                 Application Form
                                                      Licence to Store Explosives - Corporate

Scope: This application form is intended for a person applying for a Licence to Store Explosives in Queensland, other than at a Government
Magazine (refer S26, Explosives Regulation 2003). This application form must only be used by a person who is not the current holder of a licence in
Queensland under the Explosives Act 1999.

Corporate details
   Corporate name: (as displayed on the Certificate of Incorporation )

   Is this a publicly listed company or government agency ?                                                                     Yes       No
   If No, list the names in full for each person listed as a director , owner or office bearer on the Certificate of
   Incorporation or annual report :
    (1)                                    (2)                                  (3)
   (4)                                  (5)                              (6)
   Note: A security assessment form must be attached for each person listed.
   List any business or other name (s) under which you operate :

   A.B.N.                                                                               A.C.N.

   Registered business address
   Suburb or town:                                                             State:                           Postcode:
   Postal address or PO Box
   Suburb or town:                                                             State:                           Postcode:

   Contact person (for all contact from the Explosives Inspectorate - enquiries and publications )
   Title:                  First name:                                Middle name(s):

   Last name:                                                             Position:

   Business phone:                     Private phone:                     Mobile phone:                       Emergency phone:

   Fax:                                Email:                                           Web site:

          Applicant to complete payment details                                                    For office purposes only
Licence Fee:                                                                         Receipt No:                    Amount:
Application Fee :                                                                    Date of Payment :              Initials
Continued over page.                                    TOTAL:                                                          ABN: 98 628 485 885

Application Form - Licence to Store Explosives(Page 1/3)                                                                   03/01/2007 (Ver 5.5)
Licence to Store Explosives details
  Period applied for:                   1 Year        5 Year (tick one)

   Location of site administration and site contact
   Where relevant include Lot#, Mine Name, Street Name, UBD reference, GPS Coordinates
   Site name:
   Address:                                                                                          Postcode:
   First name:                       Middle name(s):              Last name:                         Phone number:

   Type of explosives to be stored
      Blasting Explosives     Propellant Powders                          If Other, specify:
      Ammunition              SSAN
      Fireworks               Other

   Explosives to be stored
   Actual Location or Identifier eg           Type                              Maximum quantity                   UN
   Name of minesite or quarry,                e.g. Blasting Explosives,         Number     Units (kg,dets)         classifications
   Address, Mag 1, Exp Mag # or Det           Fireworks, SSAN etc                                                  eg 1.1D, 1.1B, 5.1
   Mag #

   Other Storage:

   Type and quantity (tick one)
      1. Blasting explosives up to 100kg                            6. Fireworks up to 100kg (gross weight)
      2. Blasting explosives > 100kg                                7. Fireworks > 100kg (gross weight)
      3. Propellant powders up to 100kg                             8. Other explosives, up to 100kg
      4. Propellant powders > 100kg but not > 250kg                 9. Other explosives > 100kg
      5. Propellant powders > 250kg

   Previous authority
   Does the applicant currently hold , or has previously held or applied for , any                           Yes       No
   explosives authority in Queensland or another Australian state or territory ?
   If Yes, authority type:                                             Authority No:
Continued over page.

Application Form - Licence to Store Explosives(Page 2/3)                                                           03/01/2007 (Ver 5.5)
     The information entered onto this form must be printed in Blue or Black ink.
     Each box in the Required Items Section of this form must be marked with a tick if provided or a cross if not provided.
     Ensure all required information is provided by the person making application on behalf of the Corporate Entity.
     The application form must be signed and dated by the person making application on behalf of the Corporate Entity.
     Ensure the correct fee(s) is paid for the period of licence applied for (refer Explosives Information Bulletin No 37).
     All relevant details on this form must be completed.
     The original of this application should be returned to the Inspectorate. You are strongly advised to retain a copy for your own
     Required items and attachments marked [M] are mandatory and must be provided, where applicable. If a required item is not
     attached, briefly state the reason you consider it is not applicable.
     A Corporation is a Registered Company, Association or Club, Co-operative Trading Society or Government Agency. A
     Certificate of Incorporation is the document issued either under the Corporations Act 2001 by the Australian Securities
     Investment Commission (ASIC) or under the Co-operatives Act 1997 and the Associations Incorporation Act 1981 by the Office
     of Fair Trading. Downloaded information from websites is not acceptable.
     This form duly completed and all relevant attachments may be returned to the nearest office of the Explosives Inspectorate
     (refer Explosives Information Bulletin No 23). Incomplete applications will be returned without processing.
     Copies of identification and documentation must be certified by a lawyer, a notary public, a commissioner for declarations, a
     justice of the peace.
     Your name, contact details and licence details are collected for the purpose of administering the Explosives Act 1999. This
     information is not disclosed to members of the public in the usual course of business of DME without your consent.
     All explosives information bulletins and application forms can be downloaded from the Department of Mines and Energy
     website at
     Explosives must be either authorised in Queensland or approved for trial in Queensland.

     Required Items: (tick the appropriate box if attached or provided )
     Payment or proof of payment of: (a) the Licence Fee(s) and (b) the Application Fee(s). [M]
     A certified copy of the current Certificate of Incorporation and: [M]
            If a Registered Company (other than a publicly listed company or a Government Agency) : A copy of an extract from the
          ASIC register which lists the current owner(s), part-owner(s), director(s), partner(s) or other persons having an interest in
          the corporation. [M] where applicable
          If a Co-operative Trading Society : A copy of an extract of the annual return to the Office of Fair Trading (Form 9) or any
          other official documentation which provides a listing of current directors. [M] where applicable
          If an Association or Club : A copy of an extract of the annual return to the Office of Fair Trading or any other official
          documentation which provides a listing of current directors. [M] where applicable
     A completed 'Application for a Security Assessment' form, including attachments and applicable fees, for each of the listed
     persons who have an interest in the Corporation. [M]
     A copy of any equivalent authority issued to you by another regulatory authority. [M] where applicable
     A copy of the safety management system, including risk assessments, security plan, emergency response plan, procedures
     and controls, to a standard acceptable to the Chief Inspector of Explosives (refer Explosives Regulation 2003 Sections 42, 43
     & Schedule 3), unless you are a one person operation. [M] where applicable
     A plan, drawn to scale, and specification for construction of each proposed magazine/store, or description in relation to
     Australian Standard AS2187 Part 1 or other relevant standard, including a plan detailing distances to buildings and works,
     proximity to power lines and indications of numbers of people at such locations. The plan should show all facilities with the
     necessary safety distances and other supporting information. [M]
     Evidence of compliance with storage standards and codes, e.g. AS2187 Part 1 and AEISG Code. [M]
     Demonstration of SSAN compliance requirements including a completed security plan (refer Information Bulletin Nos 52, 53,
     54, 55 and 56). [M] where applicable
     Statement of reason why the licence is required, with supporting evidence. [M]
     Any other information the applicant considers appropriate in support of this application.

     DECLARATION: I, as the authorised representative of the applicant, hereby make application and declare the information
     provided to be true and accurate to the best of my knowledge at this time. Should this application be successful, the applicant
     agrees to comply with the Explosives Act 1999, Explosives Regulation 2003 and any conditions imposed.

     The applicant acknowledges that it is an offence under Section 152 of the Explosives Regulation 2003 to provide false or
     misleading information in any application for an authority or renewal of an authority. Also pursuant to Section 23(a) of the
     Explosives Act 1999, an authority issued based on incorrect or misleading information may be cancelled.

   Title:                  First name:                       Middle name(s):                  Last name:


                                                                       SIGNATURE                                     DATE
End of application.

Application Form - Licence to Store Explosives(Page 3/3)                                                        03/01/2007 (Ver 5.5)

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