This form is used to apply for a vehicle licence to transport explosives when carrying a Category 3 load only. For further information on category loads refer to the Australian Explosives Code.

Type of application:

New Renewal Replacement Amendment

Application fee: $86.00 per vehicle

TBC use only
Date received:
Fee received: $
Receipt no:
Received by (TBC staff name):

2

1. Current licence (renewal/amendment or replacement only)
Convey licence number: / Expiry date:
2. Applicant details
Company name: / ABN:
Trading name:
Contact person:
Postal address:
Suburb: / State: / Postcode:
Work number: / Mobile number:
Email address:
3. Emergency contact person
Is your emergency person the same as above? (If no, complete below) / No / Yes
Surname:
Given name/s:
Postal address:
Suburb: / State: / Postcode:
Work number: / Mobile number:
Email address:
4. Usual depot location of vehicle (must be physical address in the Northern Territory - not postal)
Site name:
Site address:
Suburb: / State: / Postcode:
5. Vehicle details
New/
Renew/Amend / Vehicle registration number / Vehicle manufacture / Vehicle model / State or Territory where vehicle is registered / Vehicle identification number (VIN) / Class/s of explosive vehicle is transporting / Explosive UN number
6. Disclosure of information
Have you ever been convicted or found guilty of any offence under the Dangerous Goods Act or Regulations in the Northern Territory, another State, and Territory or Commonwealth?
If yes, please provide details below. / No / Yes
7. Receiving licence
How do you wish to receive the licence? / Post / Email / Collection
8. 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 Competent Authority making enquiries and exchanging information with regulators in other States, Territories or the Commonwealth regarding any matter relevant to this application
Name of applicant:
Signature of applicant: / Date:

Application for an vehicle licence to transport explosives (V7.0 – 24 April 2017) 2

Checklist
Licence requirements / New / Renewal / Replacement / Amendment
Application form is complete
Declaration of applicant completed
Payment of application fee. ($86.00 per vehicle)
A self-assessment, against the requirements of the Australian Explosives Code, has been conducted for each of the vehicle listed on this application and each vehicle meets the relevant requirements of the code. A record of the self-assessment has been maintained and is available for inspection by the relevant Authority if requested.
Privacy statement
The Department of Attorney-General and Justice complies with the Information Privacy Principles scheduled to the Information Act.
Lodgement – Territory Business Centre
Incomplete applications cannot be processed and will be returned. Completed applications can be lodged in person, email or via post at a Territory Business Centre below:
Darwin
Darwin Corporate Park
Building 3
631 Stuart Highway, Berrimah / Katherine
Shop 1, Randazzo Building.
18 Katherine Terrace. / Tennant Creek
Shop 2, Barkly House
Cnr Davidson and Patterson Street. / Alice Springs
Ground Floor, The Green Well Building.
50 Bath Street
Phone address: 1800 193 111 / Email address:
Postal address: GPO Box 9800, Darwin, NT 0800
Payment details
Payment method
Cash - Territory Business Centre
Cheque - payable to RTM (Receiver to Territory Money)
Credit card
Visa / MasterCard
Name on card:
Credit card number: / Expiry:
I hereby authorise the Territory Business Centre to debit the above credit card for the amount of / $
Signature of cardholder: / Date:

For further information please contact NT WorkSafe on 1800 019 115 or go to www.worksafe.nt.gov.au

Application for an vehicle licence to transport explosives (V7.0 – 24 April 2017) 2