This form is used to apply for a replacement individual licence for Application fee: $5.50 Dangerous Goods under Regulation 5N of the Dangerous Goods Regulations and Regulation 181 of the Transport of Dangerous Goods by Road and Rail (National Uniform Legislation) Regulations. Dangerous goods class DG Driver Gasfitter Shotfirer Applicant details Surname: Given names: Date of birth: Residential address: Suburb: State: Postcode: Is your postal address the same as Yes No (If no, complete below) Postal address: Suburb: State: Postcode: Home number: Mobile number: Email address: Reason for replacement Change of name (requires evidence e.g.: marriage certificate) *no Lost Stolen fee Describe how the licence was lost, stolen or destroyed: 4. Receiving licence How do you wish to receive the licence? Post Collection 5. Declaration of applicant I do solemnly declare that the information in this application is true and correct to the best of my knowledge. I consent to the Work Health Authority making enquiries and exchanging information with WHS regulators in other States, Territories or the Commonwealth regarding any matter relevant to this application. Name of applicant: Signature of applicant: Date: Checklist Application form is complete Declaration completed
This form is used to apply for a replacement individual licence for Dangerous Goods under Regulation 5N of the Dangerous Goods Regulations and Regulation 181 of the Transport of Dangerous Goods by Road and Rail (National Uniform Legislation) Regulations. Application fee: $5.50 Dangerous goods class DG Driver Gasfitter Shotfirer Applicant details Surname: Given names: Date of birth: Residential address: Suburb: State: Postcode: Is your postal address the same as (If no, complete below) Yes No Postal address: Suburb: State: Postcode: Home number: Mobile number: Email address: Reason for replacement Lost Stolen Change of name (requires evidence e.g.: marriage certificate) *no fee Describe how the licence was lost, stolen or destroyed: 4. Receiving licence How do you wish to receive the licence? Post Collection 5. Declaration of applicant I do solemnly declare that the information in this application is true and correct to the best of my knowledge. I consent to the Work Health Authority making enquiries and exchanging information with WHS regulators in other States, Territories or the Commonwealth regarding any matter relevant to this application. Name of applicant: Signature of applicant: Date: Checklist Application form is complete Declaration completed