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Essential uses licence application form

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					                                                                             APPLICATION FOR AN ESSENTIAL
                                                                                     USES LICENCE

   Application for an Essential Uses Licence, issued under the Ozone Protection and Synthetic Greenhouse Gas Management Act 1989
   (the Act), to manufacture, import and/or export Chlorofluorocarbons (CFCs), Halons, Methyl Chloroform, Carbon Tetrachloride and
  Bromochloromethane. Essential use licence applications are considered individually on their own merit. An example of an application
 that may be considered essential use by the Department is the use of one of these chemicals for scientific experimental use where no
                                                        alternative can be utilised.

   Office Use Only                                               EUL:                                        Date received          /     /


Personal/company Details
             Name of licence holder
           (Company/importer name)
                                                                        Personal importers must provide a certified copy of their identification.

                     Trading name/s




                           ABN/ACN

                      Street address

                                                                                State                               Postcode

                      Postal address

                                                                                State                               Postcode

Contact person for information about your application
                              Name                                           Position

     Contact Numbers             BH                              Fax                                     Mobile

                              Email
                                                                                           Please circle your preferred method of contact above.

                      Postal address

                                                                                State                               Postcode


   Does this person require an interpreter when dealing with the department?                No                Yes
                                                                                                                      
                                                             What is their preferred spoken language?

Contact Person for reporting to the department

                              Name                                           Position

     Contact Numbers             BH                              Fax                                     Mobile

                              Email

                      Postal address

                                                                                State                               Postcode


   Does this person require an interpreter when dealing with the department?                No                Yes     

                                                             What is their preferred spoken language?

Customs broker details (if applicable)
          Company Name                                             Contact Person

        Contact Numbers          BH                              Fax                                        Mob

                             E-mail




FRM03.1011                                        www.environment.gov.au/gaslicence                                                     Page 1 of 3
Suitability questionnaire
The information given below must be true and correct. It is a criminal offence for a person to provide information that is false or
misleading in relation to an application made under the Ozone Protection and Synthetic Greenhouse Gas Management Act 1989
(the Act).
   You are required under section 16 of the Act to state whether you:                                                                     YES         NO

     a)      Have been convicted of an offence against the Act or the Ozone Protection and
             Synthetic Greenhouse Gas Management Regulations 1995 within the last 10 years?
     b)      Have ever contravened a condition of a licence under the Act?

     c)      Have had a licence cancelled under the Act?

     d)      Have been convicted of an offence against a law of the Commonwealth, of a State
             or of a Territory that is punishable by imprisonment for a period of 6 months or
             longer, being an offence committed within the last 10 years?
     e)      Have been declared bankrupt, have applied to take the benefit of any law for the
             relief of bankrupt or insolvent debtors, have compounded with creditors or have
             made an assignment of remuneration for their benefit?

                                 If you answered YES to any of the above questions, please give details in a separate attachment.
                                    Answering YES to any of the above will not necessarily prevent you from receiving a licence.


Details of the proposed essential use
                             For what period of time is an essential uses licence required?
          Under subsection 19(3) of the Act an essential uses licence may be granted until the end of the licence period (31 December 2011) or any shorter period specified in it.

    Please specify in the table below for which of the following activities and substances the essential uses licence is being sought,
                    and indicate the amount of substance proposed for each activity for the year of the application.

     Scheduled substances                              Import amount                                  Export amount                          Manufacture amount

   CFC-11
   CFC-12
   CFC-113
   CFC-114
   Other CFCs/Blends (specify)




   Carbon tetrachloride
   Methyl chloroform
   Halon 2402
   Bromochloromethane


                                 Details of parties proposed to be traded with
                                                                (as applicable)
      Countries from which substance(s) are proposed to be imported


           Countries to which substance(s) are proposed to be exported


    Provide information on the proposed essential use activity (please
                             indicate if additional pages are attached)




FRM03.1011                                                          www.environment.gov.au/gaslicence                                                               Page 2 of 3
                                                           DECLARATION
I declare that the above information is true and correct and that all relevant documents supporting this application are attached.
I understand that in applying for a licence I am providing permission for the Department of Sustainability, Environment, Water,
Population and Communities to access or obtain certain personal information about myself, or information about my company,
relevant to the processing of my application. I understand there are severe penalties for contravening a licence condition and for
providing false or misleading information.

         Signature of applicant or authorised
                    officer of body corporate                                                                     Date


       Name of signatory                                                             Position
                                                                         (if body corporate)

Lodging your application
Please send your application (including any attachments) to the Licensing Coordinator in the Ozone and Synthetic Gas Team:

         E-mail:           ozone@environment.gov.au OR
         Post:             GPO Box 787, Canberra ACT 2601 OR
         Fax:              (02) 6274 1610
If you require assistance completing this form, please call the Licence Coordinator on (02) 6274 1373.

The information provided in the application form helps us to assess your licence application in a timely manner. The timeframe in
which the Minister (or the delegate) must consider an application for a licence, before it is deemed refused, is 60 days unless
further information has been request from you.

Licensee information may be published on the Department of Sustainability, Environment, Water, Population and Communities
website.

Payment details
You are required to pay a $3000 application fee (no GST applies) when you submit your application.
Please note that the application fee is non-refundable. Payment can be made via electronic funds transfer (EFT) or cheque.

Banking Details
The department’s ABN is 341 908 949 83.

EFT
Bank:              Reserve Bank of Australia
Address:           London Circuit, Canberra
BSB:               092009
Account Number:    115859
Account Name:      Department of Sustainability, Environment, Water, Population and Communities
Reference:         Ozone – Your Company/Importer Name

Cheque             Please note that it may take up to 5 working days for a cheque to be cleared, which may cause a delay in
                   processing your application.
Made out to:       Department of Sustainability, Environment, Water, Population and Communities
                                 Please complete the checklist and include it in your application.
             Applicant details
             Are all applicant details complete? Personal applicants must provide a copy of their identification (e.g. driver’s licence
             or passport) that has been certified by any of the following:
                      magistrate, barrister, solicitor or patent attorney;
                      member of parliament;
                      justice of the peace;
                      an officer of the Australian Public Service (with 5 years continuous service);
                      civil marriage celebrant;
                      medical practitioner;
                      police officer in charge of a police station, or of the rank of sergeant and above;
                      bank manager; or
                      postal manager.

             Contact details
             Are all contact details complete?

             Customs broker details
             If applicable, are the shipping agent details complete?

             Details of the proposed essential use
             Have you completed all the details relating to your proposed essential use? Have you attached additional information
             (if required)?
             Payment details
             Licences will not be granted by the Minister (or the delegate) until the prescribed application fee has been received
             and cleared by the Commonwealth. Have you supplied payment of the $3000 application fee?
             Declaration
             Have you read and understood the conditions of a pre-charged equipment licence?
             Have you signed the declaration?

Please provide an estimate of the time taken to complete this form.         hrs          min

FRM03.1011                                           www.environment.gov.au/gaslicence                                          Page 3 of 3

				
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