Third Party Information Lodgment (FORM 5)

This form is used to identify information provided by a third party in respect of a notification and to indicate information whichthe third party may request not be disclosed to the notifier (‘third party confidential information’). It should be lodged with or following Form 1 (Application for Assessment Certificate or Permit for a New Industrial Chemical). While NICNAS will endeavour to uphold such requests by third parties, there may be circumstances where the disclosure of third party confidential information to the notifier is required by the Industrial Chemicals (Notification and Assessment) Act 1989 (Cth) (‘the Act’) – for example, if secondary notification of the chemical is required in accordance with Part 3, Division 6 of the Act.

If information is to be treated as exempt information under section 75 of the Act, provision of Form 3 (or declaration of exempt information on Form 1) signed by the notifier is required. Please complete form and ensure that all supporting documents are enclosed.

Return to:Director

NICNAS

GPO Box 58, Sydney NSW 2001

Telephone: (02) 8577 8800 / 1800 638 528, Fax: (02) 8577 8888

Identity of Owner of Data

Business Name:
ACN / ABN: / NICNAS Registration Number:
Business Address:
Postcode:
Postal Address (if same as Business Address, state AS ABOVE):
Postcode:
Contact Name: / Position:
Phone: / Fax: / E-mail:

Technical Contact Details for Enquiries Concerning 3rd Party Data

Business Name:
Business Address:
Postcode:
Postal Address (if same as Business Address, state AS ABOVE):
Postcode:
Contact Name: / Position:
Phone: / Fax: / E-mail:

Identity of NICNAS Notifier

Business Name:

Nov2016

NICNAS File Number (if known): / Notification Category:

Chemical Details

Chemical Name:
Marketing or Other Name(s):
CAS Number (if known):

Third Party Confidential Information

Does the third party request that information being provided in relation to this notification be kept confidential from the notifer*? / Yes No
Details of third party information which the third party requests be kept confidential from the notifier (e.g. Chemical Name):
*By signing the declaration below the third party acknowledges that there may be circumstances which require the disclosure of third party confidential information to the notifier.

Nov2016

Declaration (Owner of Data or Technical Contact)

I declare that to the best of my knowledge all the information in this application is true, correct and complete. In relation to the notification statement and/or other documentation accompanying this application, I declare that I am entitled to use and give the Director all data in the statement. This data is provided to the Director in confidence only for the purposes of the notification specified above.
Name / Position
Signature / Date
Note: It is an offence under the Act to supply a statement that is false or misleading.

Nov2016